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Adolescents and young adults (AYA) 13-24 years old make up a disproportionate 21% of new HIV diagnoses. Unfortunately, they are less likely to treat HIV effectively, with only 30% achieving viral suppression, limiting efforts to interrupt HIV transmission. Previous work with mindfulness-based stress reduction (MBSR) has shown promise for improving treatment in AYA living with HIV (AYALH). This randomized controlled trial compared MBSR with general health education (HT). Seventy-four 13-24-year-old AYALH conducted baseline data collection and were randomized to nine sessions of MBSR or HT. Data were collected at baseline, post-program (3 months), 6 and 12 months on mindfulness and HIV management [medication adherence (MA), HIV viral load (HIV VL), and CD4]. Longitudinal analyses were conducted. The MBSR arm reported higher mindfulness at baseline. Participants were average 20.5 years old, 92% non-Hispanic Black, 51% male, 46% female, and 3% transgender. Post-program, MBSR participants had greater increases than HT in MA (

Adults with special health care needs (ASHCN) face significant disparities in access to oral health care and subsequent health outcomes, resulting from several etiologies. This study investigated perspectives of patients, caregivers, and providers to better understand care barriers and facilitators for ASHCN.We conducted 26 semi-structured interviews with a purposive sample from an academic clinic specializing in oral health care for ASHCN with disabilities [patients (N = 4), caregivers (N = 8), and providers (N = 14)], and thematically analyzed transcripts for care barriers and facilitators.Three overarching themes that encompassed overlapping barriers and facilitators of oral health care for ASHCN emerged: relational aspects, provider training/ experience, and infrastructure aspects. Themes include intersecting perceptions of factors that hinder or help oral health care and management of ASHCN.Building relationships with patients, inherent empathetic provider characteristics, and accommodating clinical infrastructure are imperative to facilitate oral health care for ASHCN. The primary themes revealed in this study are facilitators to care when they are present, and barriers to care when they are absent. No individual theme stands alone as a single contributor to quality care, and the provision of care for ASHCN relies on coordination of providers, patients, caregivers, and the overarching infrastructure.

Introduction HIV is a leading cause of morbidity and mortality among youth in sub Saharan Africa. This study explores the adaptation of an adult social network intervention for adolescents, entitled Kanyakla. Methods The study was conducted in Kisumu, Kenya from July to November 2016. Data was collected from: (1) semi-structured interviews (n = 32) with adolescents living with HIV aged 15–19; and (2) two focus group discussions (n = 21). Transcripts were coded using thematic analysis through the lens of an Adolescent Development Model. Results Participants were interested in joining a Kanyakla to build social support, learn new skills, and partake in recreational activities. Many participants feared inadvertent disclosure related to stigma. Certain dichotomous themes emerged including the need for privacy versus the need for social support; and the desire for inclusion of elders versus preference for same-aged peers in the Kanyaklas. Conclusions With this study, we have key information that can be applied to developing the Kanyakla intervention for adolescents. Further study is needed to reconcile the dichotomies that emerged.

Strategies are needed to optimize HIV health care transition (HCT). We describe HCT outcomes within the University of Maryland STEP Program, which is built upon integration of an adult HIV provider and navigator into the pediatric clinic, and coordinated collaboration between pediatric and adult HIV multi-disciplinary care teams. These outcomes were compared to a historical institutional HCT cohort (

The HIV latent reservoir in resting memory CD4(+) T cells precludes cure. Therapeutics to reactivate and eliminate this reservoir are in clinical trials in adults, but not yet in pediatric populations. We determined, ex vivo, the inducibility of the latent reservoir in perinatal infection as compared with adult infections using the Tat/rev induced limiting dilution assay (TILDA), in which a single round (12 hours) of CD4(+) T cell stimulation with PMA/ionomycin maximally activates T cells and leads to proviral expression with multiply spliced HIV RNA production. Markers of immune activation and exhaustion were measured to assess interactions with inducibility. Although rates of T cell activation with PMA/ionomycin were similar, the latent reservoir in perinatal infection was slower to reactivate and of lower magnitude compared with adult infection, independent of proviral load. An enhanced TILDA with the addition of phytohemagglutin and a duration of 18 hours augmented proviral expression in perinatal but not adult infection. The baseline HLA-DR(+)CD4(+) T cell level was significantly lower in perinatal compared with adult infections, but not correlated with induced reservoir size. These data support the hypothesis that there are differences in kinetics of latency reversal and baseline immune activation in perinatal compared with adult infections, with implications for latency reversal strategies toward reservoir clearance and remission.

OBJECTIVE Conflicting data exist regarding the impact of in-utero exposure to maternal combination antiretrovirals. We compared neurodevelopmental outcomes between HIV-exposed-uninfected (HEU) children exposed in utero to three-drug combination antiretroviral therapy (ART) vs. zidovudine (ZDV) monotherapy. DESIGN Prospective study of child neurodevelopment, nested within two cohorts of HIV-infected mothers and their children in Botswana (one observational, one interventional). METHODS The Tshipidi and Mma Bana studies enrolled HIV-infected women during pregnancy and followed their HEU children for 24 months. Mothers took three-drug ART or ZDV during pregnancy. ART-exposed babies were mostly breastfed, and ZDV-exposed were formula-fed. Neurodevelopmental outcomes, measured at 24 months using Bayley Scales of Infant and Toddler Development Third Edition (Bayley-III) and Development Milestones Checklist (DMC), were compared in adjusted linear regression according to antiretroviral exposure. RESULTS Of 598 HEU children with valid neurodevelopment assessments, 382 were ART-exposed and 210 were ZDV-exposed. Adjusted mean Bayley-III scores were similar among ART-exposed vs. ZDV-exposed, with adjusted mean differences (95% confidence interval): Bayley-III Cognitive: -0.3 (-1.4, 0.9); Gross Motor: 0.8 (-0.1, 1.7); Fine Motor: 0.5 (-0.2, 1.3); Expressive Language: 0.7 (-0.3, 1.7); Receptive Language: 0.1 (-0.7, 0.8); and DMC Locomotor: 0.0 (-0.5, 0.6); Fine Motor: 0.3 (-0.3, 0.8); Language: -0.1 (-0.5, 0.4); Personal-Social: 0.2 (-0.7, 1.1). Similarly, when restricted to formula-fed children in one cohort (Tshipidi), there were no differences in adjusted mean scores. CONCLUSION Neurodevelopmental outcomes at 24 months of age were similar in ART-exposed vs. ZDV-exposed HEU children. Maternal ART with breastfeeding does not appear to have an adverse effect on neurodevelopment.

Adolescents and young adults living with HIV (YLHIV) face numerous stresses that affect their care and medication adherence. The clinic social environment may play an important supportive role for YLHIV, influencing health outcomes. The aim of this article is to explore how YLHIV in Baltimore, Maryland understand the various forms of social support provided within the social environment of their HIV clinic. We used qualitative research methods including iterative, semi-structured in-depth interviews with 20 YLHIV interviewed up to three times each to explore HIV stressors, support systems, and medication adherence. We employed thematic content analysis to systematically code and synthesize textual interview data. We found that YLHIV experienced social embeddedness with their healthcare teams and through clinic activities. Participants largely perceived these social connections as support, acknowledging that these supports are available to them when needed. Support was enacted through the provision of instrumental support for issues outside of the young person's medical care (i.e., finding a crib for a participant's baby), appraisal (i.e., through respect of the young person's agency and decision making), and information about their HIV care and medication. Support was not always well received, however, as some young people found the support from clinicians demeaning. Limitations of the clinic social support environment included concerns about trust and privacy, and perceiving support as inappropriate or unwanted. Participants identified a number of ways in which the clinic provided meaningful social support. Future research should explore how these supports may improve care and medication adherence of YLHIV.

Background Persistent HIV pre-exposure prophylaxis (PrEP) use is critical to preventing HIV acquisition. U.S. Centers for Disease Control and Prevention (CDC) recommends quarterly clinical evaluation for individuals using PrEP. Individual-level adherence to quarterly PrEP-care visits is largely unknown. Our objective was to describe patterns of quarterly PrEP-care visit attendance among individuals enrolled in a large demonstration project to increase PrEP delivery in Baltimore City, Maryland. Methods The project was a collaboration between a city health department, an academic evaluation partner, 6 clinical sites and one community based organization (CBO). Demographic and quarterly PrEP-care visit information from individuals initiating PrEP between October 1, 2015 and August 31, 2017 was abstracted from medical records using standardized forms. Participants were followed for one year. PrEP-care was categorized as ‘Persistent’ (attending all quarterly PrEP-care visits), ‘Episodic’ (missing > 1 PrEP-care visit and re-engaging PrEP-care visit), or ‘Discontinued’ (lost to follow-up after missing > 1 PrEP-care visit). Results During the study period, 333 individuals initiated PrEP, among whom 52.9% (176) were Black/African-American, 82.3% (274) cisgender male, 73.6% (245) men who have sex with men (MSM), and 47.7% (159) aged 25–24 years. 9.0% (30), 40.5% (135), and 50.5% (168) were persistent, episodic and discontinued PrEP-care users, respectively. Over half (51.1%, 69/135) of episodic users missed the first quarterly visit; mean time to PrEP re-engaging was 6.3 months (SD: 2.18). About half (45.2%, 76/168) of those discontinuing PrEP-care did so within 3-months. Conclusion Over one year, Disclosure No significant relationships.

Background Black men who have sex with men (BMSM) experience severe HIV disparities. Pre-exposure prophylaxis (PrEP) is a potential tool for reducing disparities especially when those at greatest risk are prioritized for PrEP delivery. To evaluate whether IMPACT, a multi-site PrEP demonstration project, enrolled MSM at greatest risk, this study examined associations between age, race, and HIV risk factors with PrEP program enrollment. Methods Age, (13–24, 25+), race (non-Hispanic black, non-Hispanic white, other), HIV risk factors (STI diagnosis, multiple partners in past 3 months and HIV-positive partner, condomless sex in past 12 months), and PrEP program enrollment (receipt AND acceptance of referral to PrEP provider) were collected from September 2015 through March 2018 for HIV-negative MSM screened by IMPACT. Multivariable logistic regression was used to determine the association between age, race, and HIV risk factors with PrEP program enrollment. Results IMPACT screened 1883 MSM and enrolled 1413(75.0%). 1231(65.4%) were non-Hispanic black; 484(25.7%) were 13–24; 593(31.5%) had recent STI; 802(43%) reported multiple sex partners; 832(44%) reported condomless sex and 325(17.3%) reported an HIV-positive sex partner. Individuals with black race (compared to white) (AOR=0.2; 95% CI=0.15–0.31), an HIV-positive sex partner (AOR=0.32; 95% CI=0.24–0.42), and a recent STI (AOR=0.30; 95% CI=0.24–0.39) were significantly less likely to be enrolled. Individuals with multiple partners (AOR=1.34; 95% CI=1.04–1.73), age 13–24 (AOR=1.99; 95% CI=1.49–2.65), and condomless sex (AOR=2.24; 95% CI=1.74–2.88) were significantly more likely to be enrolled. Conclusion These findings suggest significant barriers to PrEP enrollment for BMSM which may widen rather than reduce HIV disparities. Importantly, youth and MSM reporting condomless sex and multiple partners were more likely to be enrolled. Yet, negative associations between enrollment and black race, recent STI, HIV-positive sex partners suggest critical challenges engaging MSM at greatest risk for HIV which may diminish PrEP effectiveness as a public health prevention tool if unaddressed. Disclosure No significant relationships. ART, PrEP, gay bisexual and other men who have sex with men, USA

Background Bacterial STIs such as syphilis, rectal gonorrhea (GC) and chlamydia (CT) are strongly associated with increased risk of HIV acquisition, and are a marker of ongoing sexual risk behavior among HIV pre-exposure prophylaxis (PrEP) users. STI positivity among men who have sex with men (MSM) PrEP-users in settings where PrEP has been implemented is understudied. Our objective was to determine syphilis and rectal GC/CT positivity among MSM PrEP-users enrolled in a large PrEP demonstration project in Baltimore City, Maryland. Methods The demonstration project was a collaboration between a city health department, an academic evaluation partner, six clinical sites and one CBO. STI results at PrEP initiation and routine 6- and 12-month PrEP-care visits were collected among MSM receiving PrEP at participating clinical sites between September 30, 2015-March 31, 2018. Syphilis and rectal GC/CT positivity was calculated among those screened at each visit. Results During the study period, 290 MSM initiated PrEP, of whom 46.9%(136) were Black/African-American, and 51.4%(149) aged 25–34 years. At PrEP initiation, 79.2%(230) and 56.1%(165) were screened for syphilis and rectal GC/CT, respectively; the proportion screened at 6- and 12-month PrEP-care visits was slightly lower. Overall, including PrEP initiation and care visits, 11.6%(30/258) were ever syphilis positive, 17.9%(35/196) ever rectal GC positive, and 22.5%(44/196) ever rectal CT positive. Specifically, at PrEP initiation, 7.8%(18/230) were syphilis positive; 11.1%(18/162) rectal GC positive, and 11.7% (19/162) rectal CT positive. Positivity at 6- and 12-month PrEP-care visits was similar to positivity at PrEP initiation. Conclusion Despite CDC recommendations for biannual STI screening among PrEP-users, the proportion of MSM PrEP-users screened was suboptimal. The overall and ongoing positivity of syphilis and rectal GC/CT suggest that a substantial proportion of MSM PrEP-users may be engaging in ongoing sexual risk behaviors. Strategies are needed to encourage providers to screen PrEP-users more frequently for STIs and promote safer sexual practices. Disclosure No significant relationships.

Background Pre-exposure prophylaxis (PrEP) is a potential tool for reducing racial HIV disparities by reducing HIV acquisition among those at greatest risk. A recent bacterial STI is an important biomarker of HIV acquisition risk and represents one target for prioritizing PrEP in populations with the greatest HIV burden. Receipt of a PrEP prescription is an important step of the PrEP cascade. This study assessed whether race and recent STI diagnoses were associated with receipt of a PrEP prescription among men who have sex with men (MSM) in a PrEP program. Methods Race (non-Hispanic black, non-Hispanic white, other), recent STI diagnosis (self-reported diagnosis in past 3 months) and data on receipt of a PrEP prescription among MSM who met clinical eligibility criteria for PrEP were collected from September 2015 through March 2018. Participants were enrolled at one of six clinical sites participating in IMPACT, a multi-site PrEP demonstration project. Multivariable logistic regression analysis was used to determine the associations between race and recent STI diagnosis with receipt of a PrEP prescription. Results IMPACT screened 308 MSM as clinically eligible for PrEP and 287(93.2%) received a PrEP prescription; 153(49.7%) were non-Hispanic black and 109(35.4%) reported an STI diagnosis. MSM with black race (compared to white) (AOR=0.170; 95% CI=0.047–0.607) were significantly less likely to receive a PrEP prescription. MSM with a recent STI diagnosis (AOR=4.874; 95% CI=1.377–17.249) were more likely to receive a PrEP prescription. Conclusion MSM with recent STI diagnosis were more likely to receive PrEP prescriptions. The finding that black MSM are less likely to receive prescriptions suggest a barrier to PrEP delivery that may widen rather than reduce HIV disparities. Identifying and understanding these barriers to PrEP delivery are an important target for future research. Disclosure No significant relationships.

Background: Innovative strategies and protocols are required for effective provision of healthcare services and attainment of optimal positive health outcomes for adolescents living with HIV (ALHIV) as they transition to adult care.HIV-infected youth must learn to navigate a complex healthcare system as they transition from pediatric to adult care. Poorly planned transitions can result in non-adherence to ART, loss-to-follow-up in care and supportive services, with resultant negative health impact. This study evaluates two different approaches to the process of transition from pediatric to adult care in six facilities in Nigeria. Methods: ADAPT will use a cluster randomized intervention trial to measure the impact of Peer Transition Advocates (PTAs) versus Education Interventionists (EIs) approach to the process of transition of ALHIV, with imbedded psychosocial/social network analyses. The study will be conducted in 6 healthcare facilities (three tertiary and three secondary) in Northern and Central Nigeria. The unit of randomization (cluster) will be the facilities (n=180 per intervention arm, N=360), study participants 17-19 year-old ALHIV enrolled in the pediatric ART clinic for ≥12 months and know their HIV status. Sixty participants will be recruited pre-transition per site and followed up 12 months post-transition. Primary outcome measure will be proportion of ALHIV achieving successful transition and viral suppression 12 months post-transition comparing the two arms. Secondary outcome measures are proportion of ALHIV achieving ownership of care, improved quality of life, better transfer experience, and social support system measured by individual and ego-network evaluation tools correlating with successful transition. Discussion: ADAPT hypothesizes that by involving ALHIV in the study design, the PTA intervention will result in more successful transition and clinical outcomes in adult care. Further, we postulate that properly trained and supervised task-oriented peer support using lay workers assigned to track and guide each adolescent along the transition pathway in the clinic and in the community is the key starting point for transforming a dysfunctional system. Findings from ADAPT will guide institutions on best practices for transitioning ALHIV and other adolescents with chronic conditions in Nigeria and other resource-limited settings.

Patients with perinatally acquired HIV may be at risk for the development of age-related non-AIDS diseases. The primary aim of this study was to describe patterns of systemic hypertension among a cohort of adults (≥18 years) with perinatally acquired HIV. A retrospective cohort study was conducted among adults (≥18 years) with perinatally acquired HIV infection. Primary outcomes included documentation of systemic hypertension as well as several additional non-AIDS-associated illnesses. Systemic hypertension incidence rates and rate ratios (RRs) were calculated among groups aged ≥18 and

BACKGROUND: In utero exposure to nucleoside reverse transcriptase inhibitor (NRTI)-containing antiretroviral treatment (ART) regimens may be associated with poor neurodevelopmental functioning in children of HIV-infected mothers. We investigated neurodevelopmental outcomes of HIV-exposed uninfected (HEU) children of HIV-infected women enrolled in a randomized trial of abacavir/zidovudine/lamivudine (Triple-NRTI regimen) vs. lopinavir/ritonavir/zidovudine/lamivudine (Dual NRTI+PI regimen). SETTING: The Mma Bana randomized trial was conducted in urban and rural sites in Botswana. METHODS: The Mma Bana study randomized HIV-infected pregnant women with CD4 ≥ 200 cells/mm(3) to a triple-NRTI vs. dual-NRTI+PI regimen from 26–34 weeks gestation through planned weaning at 6 months postpartum. Partway through the study, neurodevelopmental assessments were added at 24 months of age, including the Developmental Milestones Checklist, the Bayley Scales of Infant and Toddler Development 3(rd) edition, Ten Questions Questionnaire, and Profile of Social Emotional Development. We evaluated differences in mean scores between the two arms using unadjusted and adjusted linear regression. RESULTS: A total of 197 HEU infants (48% male) completed a neurodevelopmental assessment (101 in triple-NRTI arm; 96 in dual-NRTI+PI-exposed arm). Means for all neurodevelopmental outcomes were similar for children of mothers randomized to either ART regimen, with no significant differences in either unadjusted or adjusted models (estimated effect sizes ranging from −0.12 to 0.14). CONCLUSION: Neurodevelopmental outcomes in 24-month-old HEU children of HIV-infected mothers with baseline CD4≥200 were similar in those randomized to a dual-NRTI+PI-based versus a triple-NRTI-based ART regimen, suggestive of lack of short term toxicity. Monitoring of long term toxicity and newer regimens is warranted.

BACKGROUND:We sought to determine if HIV-exposed uninfected (HEU) children had worse neurodevelopmental outcomes at 24 months compared with HIV-unexposed uninfected (HUU) children in Botswana.METHODS:HIV-infected and uninfected mothers enrolled in a prospective observational study (“Tshipidi”) in Botswana from May 2010 to July 2012. Child neurodevelopment was assessed at 24 months with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III: cognitive, gross motor, fine motor, expressive language, and receptive language domains) and the Development Milestones Checklist (DMC), a caregiver-completed questionnaire (locomotor, fine motor, language and personal-social domains). We used linear regression models to estimate the association of in-utero HIV exposure with neurodevelopment, adjusting for socioeconomic and maternal health characteristics.RESULTS:We evaluated 670 children (313 HEU, 357 HUU) with ≥1 valid Bayley-III domain assessed and 723 children (337 HEU, 386 HUU) with a DMC. Among the 337 HEU children with either assessment, 122 (36%) were exposed in utero to maternal 3-drug antiretroviral treatment and 214 (64%) to zidovudine. Almost all HUU children (99.5%) breastfed, compared with only 9% of HEU children. No domain score was significantly lower among HEU children in adjusted analyses. Bayley-III cognitive and DMC personal-social domain scores were significantly higher in HEU children than in HUU children, but differences were small.CONCLUSIONS:HEU children performed equally well on neurodevelopmental assessments at 24 months of age compared with HUU children. Given the global expansion of the HEU population, results suggesting no adverse impact of in-utero HIV and antiretroviral exposure on early neurodevelopment are reassuring.

Introduction: The transition from paediatric to adult care poses risks to the health of young adults living with HIV if unsuccessful, including interruptions in care and poor health outcomes. Evolving best practices in HIV healthcare transition should ideally be informed by real-world qualitative and quantitative clinical healthcare transition outcomes. There has been a recent proliferation of HIV healthcare transition outcome research, largely from Europe and North America. Methods: A literature search was undertaken using the online databases PubMed, Web of Science, and Google Scholar. Medical subject and text word searches were combined for terms relating to HIV, paediatric transition outcomes, and internal and external factors were used to identify peer-reviewed articles. Results: In this paper, we review data on HIV healthcare transition outcomes in North America and Europe. Internal and external factors which may impact the success of HIV healthcare transition are examined. We describe ongoing research efforts to capture transition outcomes in the North America and Europe. Clinical, operational, and implementation science research gaps that exist to date are highlighted. Efforts to improve HIV healthcare transition research through country-level surveillance networks and large multicentre cohorts, including data integration and linkage between paediatric and adult cohorts are discussed. Conclusions: We identified the need for a comprehensive approach to implementing empirically supported protocols to support healthcare transition for ALHIV. While there is limited prospective longitudinal cohort data available at this time, cohorts linking the paediatric and adolescent with ongoing surveillance into adulthood are being developed. Through a review of existing qualitative and quantitative healthcare transition outcomes studies, we identify emerging areas of consensus surrounding healthcare transition research implementation. Successful healthcare transition programmes in Europe and North America often share several characteristics, including implementation of a youth friendly multidisciplinary approach, consistent communication and integration between paediatric and adult care teams, and an individualized approach which is attuned the adolescent’s transition readiness. Moving forward, the voices of youth and young adults living with HIV should be included in the development and evaluation of healthcare transition protocols to ensure that the definition of successful transition reflects all of the stakeholders in the transition process.

Outcomes following healthcare transition (HCT) from pediatric to adult HIV care are not well described. We sought to describe clinical outcomes following HCT within our institution among young adults with behavioral-acquired (N = 31) and perinatally-acquired (N = 19) HIV. We conducted a retrospective cohort study among HIV-infected adults who attempted transition from pediatric to adult HIV care within our institution. The primary end point was retention in care, defined as the completion of at least two visits over 12 months following linkage to adult care. Additional end points include time to linkage to adult care, and changes in CD4 + T cell count and HIV RNA across time. Outcomes were compared between perinatal and behavioral HIV cohorts. Binary data were analyzed using the Fisher exact test and continuous data were analyzed using the Mann-Whitney test. Forty-three (86%) of 50 patients were successfully linked to adult care. The median time to linkage was 98 days. Fifty percent of patients achieved full retention in care at 12 months post-linkage. Though those with behavioral-acquired HIV attempted transfer at an older age, the groups did not differ in rates of linkage and retention in adult care. CD4 + T cell counts and rates of viral suppression did not differ between pre- and post-HCT periods. Despite high rates of successful linkage to adult care in our study population, rates of retention in adult HIV care following HCT were low. These results imply that challenges remain in the adult HIV care setting toward improving the HCT process.

With widespread access to antiretroviral therapy in the United States, many perinatally HIV-infected (PHIV+) children are surviving into adolescence and adulthood, becoming sexually active and making decisions about their reproductive health. The literature focusing on the reproductive decisions of individuals behaviorally infected with HIV can serve as a springboard for understanding the decision-making process of PHIV+ youth. Yet, there are many differences that critically distinguish reproductive health and related decision-making of PHIV+ youth. Given the potential public health implications of their reproductive decisions, better understanding of factors influencing the decision-making process is needed to help inform the development of salient treatment and prevention interventions. To begin addressing this understudied area, a “think tank” session, comprised of clinicians, medical providers, and researchers with expertise in the area of adolescent HIV, was held in Bethesda, MD, on September 21, 2011. The focus was to explore what is known about factors that influence the reproductive decision-making of PHIV+ adolescents and young adults, determine what important data are needed in order to develop appropriate intervention for PHIV+ youth having children, and to recommend future directions for the field in terms of designing and carrying out collaborative studies. In this report, we summarize the findings from this meeting. The paper is organized around the key themes that emerged, including utilizing a developmental perspective to create an operational definition of reproductive decision-making, integration of psychosocial services with medical management, and how to design future research studies. Case examples are presented and model program components proposed.

Background Pre-exposure prophylaxis (PrEP) is the newest biomedical HIV prevention option. The daily tenofovir/emtricitabine (Truvada) combination pill reduces the risk of HIV infection by up to 92% compared to placebo (1). While PrEP use is increasingly common in adult LGBT populations, only a handful of studies have investigated introducing PrEP to adolescent providers and patients. Adolescents are the fastest growing age group of HIV positive patients and LGBT youth are at even higher risk. Nationally, 19% of new HIV infections occur in LGBT youth. HIV infections in LGBT youth …

Summary Freedman D, Koenig LJ, Wiener J, Abrams EJ, Carter RJ, Tepper V, Palumbo P, Nesheim S, Bulterys M. Challenges to re-enrolling perinatally HIV-infected and HIV-exposed but uninfected children into a prospective cohort study: strategies for locating and recruiting hard-to-reach families. Paediatric and Perinatal Epidemiology 2006; 20: 338–347. Children infected with the human immunodeficiency virus (HIV) are living longer. Studies aimed at understanding the health and well-being of these children as they age into adolescence are enhanced by research designs that include appropriate comparison groups. HIV-exposed but uninfected children are one such comparison group; however, recruitment of this comparison group is challenging because uninfected children may no longer be followed at tertiary care centres, and some may be in foster care or no longer living with their biological parents. This paper describes the recruitment methods, sampling plan, and factors associated with enrolling perinatally HIVinfected children and a comparison group of HIV-exposed but uninfected children into the HIV Follow-up Of Perinatally Exposed Children (PACTS-HOPE) prospective cohort study. The source population consists of HIV-infected and uninfected children originally enrolled in the Perinatal AIDS Collaborative Transmission Study (PACTS). Recruitment took place at paediatric HIV clinics in four US locations between March 2001 and March 2003. A total of 182 HIV-infected and 180 uninfected children were enrolled. Enrolment of uninfected children was much harder than that of infected children because the former often could not be located. After adjusting for site and birth-year category, uninfected children born to white mothers were significantly less likely to be enrolled ( P < 0.01). There was a trend for infected and uninfected children of mothers with a history of injection drug use to enrol at lower rates. Although recruitment of the uninfected comparison group was challenging, it was nevertheless facilitated by hierarchical recruitment techniques, involvement of family networks, and continuity of study staff. The PACTS-HOPE cohort will provide opportunities for future research aimed at understanding the unique effects of HIV on the well-being of HIV-infected children.

Although parents and caregivers may have primary responsibility for their children's medication- taking, surprisingly few studies have examined caregiver psychosocial correlates of children's adherence to antiretroviral therapy (ART). This cross-sectional, descriptive study examined the relationship between caregiver psychosocial characteristics and medication adherence among children with HIV. Fifty-four caregivers of children with HIV completed a demographic questionnaire, the Parenting Stress Index, the Brief Symptom Inventory, the Family Support Scale, and the Support Functions Scale. Adherence to ART was measured with children's 6-month pharmacy refill histories. Children and caregivers were primarily African American, urban, and poor (63% reported$15,000 annual household income). Univariate analyses showed that an adherent classification (/= 80% refill rate) was associated with shorter duration of highly active antiretroviral therapy (HAART) treatment, nondisclosure of the HIV diagnosis to the child, lower caregiver income level, having a nonbiologically related caregiver, and less caregiver psychiatric distress. In a multivariate logistic regression, duration of child's HAART treatment, child HIV disclosure status, caregiver income, and caregiver psychiatric distress accounted for 63% of the variance in adherence. Findings highlight the complexity of children's adherence to ART and the need for multicenter studies with greater sample sizes to explore in more detail the effects of caregiver psychological distress and child HIV disclosure status on adherence as well as the ways in which regimen fatigue and adherence fluctuate over time.

OBJECTIVE Examine the 24-hr Recall Interview (24RI) for assessing children's antiretroviral medication adherence. METHODS Caregivers of 54 children with HIV (aged 2-12 years) completed a clinical adherence interview and the 24RI by telephone. Children's viral load and 3-month pharmacy records were obtained. RESULTS Thirty-seven percent of children missed > or = 1 dose of medicine over 3 days. In 22% of the samples, adherence varied across medications. The 24RI adherence scores (Frequency, Interval, and Dietary Adherence) were moderately reliable across the three interviews. Pharmacy refill rates were significantly related to viral load, and 24RI barriers were marginally significantly related to viral load. CONCLUSIONS The 24RI, with its systematic, cued recall, and decreased focus on adherence, may reduce socially desirable responding compared to other self-report methods, and reporting adherence barriers may indicate adherence difficulty. However, the validity of the 24RI must be improved to make it a useful measure to include in an adherence assessment battery.

The authors sought to assess the utility of the electronic Medication Event Monitoring System (MEMS) in monitoring adherence to highly active antiretroviral therapy (HAART) in HIV-infected children and to compare this with other methods of adherence assessment. Twenty-six perinatally HIV-infected children being treated with three or more antiretroviral medications and their caregivers were enrolled and prospectively followed-up for 6 months. Adherence was assessed using MEMS monitoring of one antiretroviral, pharmacy refill records of all antiretrovirals, a caregiver self-report interview, a physician/nurse questionnaire, and appointment-keeping behavior. Viral loads measured at the end of the 6-month period were compared with the various adherence assessment methods. Adherence rates for the MEMS-monitored medication ranged from 12.7% to 97.9% (median = 81.4%), and 11 of the participants (42%) had less than 80% adherence using this method. A MEMS adherence rate greater than 80% was associated with viral load below the threshold of detection 6 months after enrollment (p

Introduction : The transition from paediatric to adult care poses risks to the health of young adults living with HIV if unsuccessful, including interruptions in care and poor health outcomes. Evolving best practices in HIV healthcare transition should ideally be informed by real-world qualitative and quantitative clinical healthcare transition outcomes. There has been a recent proliferation of HIV healthcare transition outcome research, largely from Europe and North America. Methods : A literature search was undertaken using the online databases PubMed, Web of Science, and Google Scholar. Medical subject and text word searches were combined for terms relating to HIV, paediatric transition outcomes, and internal and external factors were used to identify peer-reviewed articles. Results : In this paper, we review data on HIV healthcare transition outcomes in North America and Europe. Internal and external factors which may impact the success of HIV healthcare transition are examined. We describe ongoing research efforts to capture transition outcomes in the North America and Europe. Clinical, operational, and implementation science research gaps that exist to date are highlighted. Efforts to improve HIV healthcare transition research through country-level surveillance networks and large multicentre cohorts, including data integration and linkage between paediatric and adult cohorts are discussed. Conclusions : We identified the need for a comprehensive approach to implementing empirically supported protocols to support healthcare transition for ALHIV. While there is limited prospective longitudinal cohort data available at this time, cohorts linking the paediatric and adolescent with ongoing surveillance into adulthood are being developed. Through a review of existing qualitative and quantitative healthcare transition outcomes studies, we identify emerging areas of consensus surrounding healthcare transition research implementation. Successful healthcare transition programmes in Europe and North America often share several characteristics, including implementation of a youth friendly multidisciplinary approach, consistent communication and integration between paediatric and adult care teams, and an individualized approach which is attuned the adolescent’s transition readiness. Moving forward, the voices of youth and young adults living with HIV should be included in the development and evaluation of healthcare transition protocols to ensure that the definition of successful transition reflects all of the stakeholders in the transition process. Keywords HIV; AIDS; healthcare transition; adolescent; youth (Published: 16 May 2017) Tepper V et al. Journal of the International AIDS Society 2017, 20(Suppl 3) :21490 http://www.jiasociety.org/index.php/jias/article/view/21490 | http://dx.doi.org/10.7448/IAS.20.4.21490

Palliative care (PC), introduced early in the management of chronic illness, improves patient outcomes. Early integration of a palliative approach for persons with HIV has been documented to be effective in identifying and managing patient-level concerns over the past decade in African settings. The experience of implementing PC in multiple African and other resource-constrained settings (RCSs) emphasizes the need for essential palliative competencies that can be integrated with chronic disease management for patients and their families facing life-limiting illness. This article is an historical description of how basic palliative competencies were observed to be acceptable for health workers providing outpatient HIV care and treatment during eight years of U.S. implementation of "care and support," a term coined to represent PC for persons living with HIV in RCS. The need for team building and interprofessional education is highlighted. The model is currently being tested in one U.S. city and may represent a mechanism for expanding the palliative approach into management of chronic disease. Such competencies may play a role in the development of the patient-centered medical home, a critical component of U.S. health care reform.

Pediatric neuro-AIDS may be the first clinical manifestation of HIV infection in children born to HIV infected mothers. As part of the neurodevelopmental examination of children, the Clinical Adaptive Test/Clinical Linguistic and Auditory Milestone Scale (CAT/CLAMS) was investigated as a tool for pediatricians to use to monitor the development of children at risk for HIV infection. The CAT/CLAMS was found to detect neurodevelopmental differences between HIV-infected and uninfected children at 12 and 18 months of age. Good correlations were found between the CAT/CLAMS and concurrently administered Bayley Scales of Infant Development. These findings suggest that the CAT/CLAMS should be considered as a part of the neurodevelopmental examination of children at risk for pediatric neuro-AIDS.

Scores from the Alcohol Use Disorders Identification Test (AUDIT) and the Center for Epidemiological Studies Depression Scale (CES-D) administered to both antiretroviral therapy (ART)-experienced and -naive adults in HIV care in Nigeria were evaluated for association with participant characteristics and ART adherence measured by pharmacy records. Participants included 222 ART-experienced and 177 ART-naive adults, of whom 47 (12%) had AUDIT >/=8, 29 (7%) an AUDIT >/=10, 52 (13%) a CES-D >/=16, and 25 (6%) a CES-D >/=21. An elevated AUDIT score was more frequent among ART-naive and men, while disclosure of HIV status to others was associated with lower scores. An elevated CES-D score was more frequent among ART-naive and those with lower educational level, while disclosure of HIV status and choosing to be interviewed in English rather than Hausa was associated with lower scores. An elevated CES-D score was associated with poor adherence.

This study sought to examine predictors of psychological symptoms and psychiatric service receipt among youth with HIV. Data were from the baseline assessment of Adolescent Impact, a study of 13-21-year-old youth with HIV in three US cities. Between August 2003 and February 2005, participants completed the age-appropriate youth or adult self-report symptom checklists (Achenbach system of empirically based assessment) and reported their psychiatric treatment history. Psychiatric diagnoses were abstracted from medical records. The 164 participating youth living with HIV were Black (81%), female (52%), Heterosexually identified (62%), and perinatally HIV-infected (60%). Thirty-one percentage reported levels of internalizing (i.e., self-focused/emotional), externalizing (i.e., outwardly focused/behavioral), or overall symptoms consistent with clinical psychopathology. In multivariate analyses, questioning one's sexual identity was associated with greater internalizing problems, whereas identifying as Bisexual was associated with greater externalizing problems (p0.05). Symptoms were not associated with HIV transmission group. Participants withor =1 composite score within the clinical range were more likely to have receivedor =1 psychiatric service (Odds ratio (OR): 2.51; 95% confidence interval (CI): 1.22, 5.13) and a psychiatric diagnosis in the past year (OR: 2.16; 95% CI: 1.09, 4.27). However, 27% with clinically elevated scores had never received psychiatric care. Results suggest that among youth with HIV, those who identify as Bisexual or Questioning are at greatest risk for emotional and behavioral problems. Despite available mental health services, some youth with HIV are not receiving needed mental health care. Enhanced evaluation, referral and mental health service linkage is needed for these high-risk youth.

Medication adherence is critical for children’s HIV treatment success, but obtaining accurate assessments is challenging when complex measurement technologies are not feasible. Our goal was to evaluate a multidimensional adherence interview designed to improve upon existing adherence measures. Data from caregivers (N = 126) of perinatally infected children were analyzed to determine the ability of the revised interview guide to detect potential treatment non-adherence. Questions related to viral load (VL) on a bivariate level included proportion of doses taken in the previous 3 days and 6 months, caregivers’ knowledge of prescribed dosing frequencies, and caregivers’ reports of problems associated with medication administration. VL was not associated with 3-day recall of missed doses. In multivariate analyses, only caregiver knowledge of prescribed dosing frequencies was uniquely associated with VL. Our modified interview appears to successfully identify family struggles with adherence and to have the capacity to help clinicians address medication adherence challenges.

This study examines the relationship between adherence to pediatric HIV regimens and three family experience factors: (1) regimen responsibility; (2) barriers to adherence; and (3) strategies for remembering to give medications. Caregivers of 127 children ages 2-15 years in the PACTS-HOPE multisite study were interviewed. Seventy-six percent of caregivers reported that their children were adherent (takingor = 90% of prescribed doses within the prior 6 months). Most caregivers reported taking primary responsibility for medication-related activities (72%-95% across activities); caregivers with primary responsibility for calling to obtain refills (95%) were more likely to have adherent children. More than half of caregivers reported experiencing one or more adherence barriers (59%). Caregivers who reported more barriers were also more likely to report having non-adherent children. Individual barriers associated with nonadherence included forgetting, changes in routine, being too busy, and child refusal. Most reported using one or more memory strategies (86%). Strategy use was not associated with adherence. Using more strategies was associated with a greater likelihood of reporting that forgetting was a barrier. For some families with adherence-related organizational or motivational difficulties, using numerous memory strategies may be insufficient for mastering adherence. More intensive interventions, such as home-based nurse-administered dosing, may be necessary.

This paper presents findings of a multi-site study designed to document: (1) caregivers' regimen knowledge; (2) barriers to adherence; and (3) the relationships between adherence, regimen knowledge and barriers. Fifty-one predominantly female, African American parents and caregivers of HIV-infected children completed the Treatment Interview Protocol (TIP), a brief, structured interview designed to assess regimen knowledge and barriers to adherence. TIP data were compared to information obtained from medical records and pharmacy refill histories. Forty-nine per cent of children were considered adherent, defined asor = 90% refill rate, which was significantly associated with virologic response. Significant regimen knowledge deficits were observed among caregivers, and inaccurate identification of prescribed medications was significantly associated with adherence. Caregivers identified 21 barriers to adherence, and poor adherence was significantly related to the number of barriers reported. Results indicate that the TIP is a successful tool for identifying regimen knowledge, potential adherence barriers and adherence problems. Results suggest that the TIP could be integrated into clinical practice as a quick, effective tool to identify poor adherers and guide interventions and treatment decision making.

• Objective. —The objectives of this study were to assess the current and chronic health problems and the adequacy of primary health care of children placed with a relative (kinship care) by a public agency. Research Design. —Population survey. Setting. —Children in kinship care in Baltimore, Md. Participants. —Four hundred seven (78%) of 524 children in kinship care in 1989. Interventions. —None. Measxurements/Main Results. —Information on the child's health status and care was obtained via a review of medical records; questionnaires sent to primary care physicians, parents, care givers, and caseworkers; and clinical assessment of the child by a nurse, pediatrician, and child psychologist. The children were found to have health problems similar to those in foster and poor children, but more problems than American children in general. Frequent diagnoses included impaired visual acuity and hearing, obesity, dental caries, and asthma; often, these problems had not been identified or treated. Gaps in the medical records precluded firm conclusions concerning the children's primary care, but suggest an inadequate system for ensuring their health care. Conclusions. —There is a need for improving the system of health care for children in kinship care. There is also a need for additional research on this high-risk group of children. ( AJDC . 1992;146:603-610)

In three studies, core temperatures of immature chicks rose during immobilization induced by simulated predation and fell rapidly when immobilization terminated. Immobilization termination was predicted by proximity of the core temperature to the daily resting core temperature of adult fowl. Although immobilization duration increased with age and was shorter in cold and hot environments, immobilization terminated at the same core temperature at all ages and ambient temperatures. The common termination temperature and pattern of temperature change across all Ss suggests that immobilization is terminated in response to the demand that the rising core temperature be behaviorally maintained within a vital range. The generality of this finding was confirmed in a fourth study with preweanling kittens during exhibition of the transport response--an immobilization reaction with a different evolutionary history. These findings reveal that when immobilization and behavioral thermoregulation present conflicting survival demands for avian and mammalian young, the control of core temperature assumes behavioral priority.

Background. Neurodevelopmental impairment has been identified in children infected with human immunodeficiency virus (HIV). The frequency and spectrum of neurologic impairment are greater in children than those reported for adults. In children, HIV is known to enter the central nervous system early in the course of the disease. The presentation of pediatric neuro-acquired immune deficiency syndrome ranges from static (eg, nonprogressive developmental delay) to progressive encephalopathy (eg, acquired microcephaly, pyramidal tract signs, and spasticity). It has been demonstrated that antiretroviral agents can improve or even reverse the course of neurologic impairment in children. These changes have been attributed to various degrees of central nervous system drug penetration. Increasingly, protease inhibitors and combination antiretroviral therapy using reverse transcriptase inhibitors are being used in the treatment of children infected with HIV. The addition of a protease inhibitor to nucleoside analogue therapy has been reported to delay disease progression and prolong life in adults with moderate to advanced HIV disease. No data currently exist on the impact of combination therapy using two nucleoside analogues and a protease inhibitor on neurodevelopmental and neurologic function in children with HIV infection. The following case report presents the effects of combination therapy using ritonavir in a child infected with HIV. Case Report. An 8-year, 2-month-old African-American boy was infected with HIV through vertical transmission. Regular monitoring of the patient's neurodevelopmental status has been conducted as part of his participation in longitudinal research protocols. For the first 5½ years of life, his neurodevelopmental status was normal, with cognitive functioning as measured by standardized psychometric tools solidly in the average range. Speech and language skills were age-appropriate. Tests of gross and fine motor functioning as well as evaluation of overall neurodevelopmental status suggested normal development. Magnetic resonance imaging (MRI) of the brain was consistently normal. His family reported that adaptive functioning, peer and family relationships, and behavior were all within normal limits. School reports indicated consistently that the patient was performing at age and grade level, with respect to both academic achievement and behavior. Initial concerns regarding the patient's development were expressed by both his family and school at age 6 years, 6 months. These concerns included difficulty with classroom work, decreased attention, word-finding problems, fatigue, staring spells, and loss of strength. His family and school reported a marked loss of skills acquired previously. Results of formal psychological and speech and language evaluation reflected statistically significant drops in test scores from baseline, with both delayed and atypical skills evident. The patient's condition worsened rapidly. Within a few months, he was no longer able to use sentences to communicate. Cognitive testing was attempted, but he was unable to participate because of significant fatigue, limited attention, and inability to communicate verbally. His family described periods of disorientation and confusion, lethargy, and disinterest in age-appropriate activities. He became agitated and overstimulated easily both in small group settings and in crowds. He demonstrated both fine and gross motor impairments. When frustrated, he displayed infantile and autistic-like behavior. MRI with contrast showed diffuse atrophy as well as mild prominence of the ventricles and sulcii compared with baseline assessment. In addition to fatigue and neurologic symptoms, wasting syndrome was diagnosed, with loss of percentiles in both weight and height by age 7½ years. Low-grade elevation of liver function tests and amylase was noted. Blood cultures for mycobacteria were negative, as were serologic tests for hepatitis. Previous antiviral treatment had included zidovudine monotherapy begun at age 20 months through AIDS Clinical Trials Group protocol 128. This was changed to dideoxyinosine monotherapy through AIDS Clinical Trials Group protocol 144 at 4 years of age, which was discontinued at age 6.5 years because of pancreatitis. A brief course of stavudine monotherapy was associated with recurrence of pancreatitis. Zidovudine monotherapy was reinstated at age 7 years. With the availability of new medications, at age 7 years, 9 months, the patient began combination therapy with ritonavir (350 mg/m2 per dose twice a day), zidovudine (120 mg/m2 per dose every 8 hours), and 3TC (4 mg/kg per dose twice a day). In the 6 months since the initiation of combination therapy, we have observed significant changes in the patient's neurodevelopmental functioning. Substantial improvements have occurred in both his cognitive and his language functioning. Improvements in laboratory measures were noted, as well as a three-log reduction in viral load and a significant increase in CD4+ T-lymphocyte percents and total counts. Repeat MRI of the brain was performed that demonstrated normal size of the ventricular system and cerebral volume, compared with the earlier study, which had shown diffuse atrophic changes. Signal intensity of the white matter was normal on all sequences, and no mass lesions were noted. These changes were consistent with the resolution of all previous abnormal findings. Discussion. In a short time, we have observed and documented a dramatic recovery in our patient's virologic, hematologic, and neurodevelopmental functioning as shown in neuroradiographic imaging after initiation of combination therapy. These positive changes suggest that the use of combination therapy not only significantly suppresses HIV replication, but can also lessen or even reverse some of the neurologic and neurodevelopmental sequelae of neuro-acquired immune deficiency syndrome. If these findings are replicated in other HIV-infected children using combination therapy, it will reinforce the importance of aggressive, combination treatment for children.

Objectives: To determine the characteristics of children in kinship care and their caregivers who have access to health care (a single source of health care or a single provider), and to determine the relation between indicators of access and health needs. Design: Cross-sectional. Setting: A large eastern city. Subjects: Two hundred ten children selected from households with children in kinship care in April 1989. Methods: Data were obtained from medical records, access and demographic questionnaires, and a medical and psychologic evaluation. Results: A single facility for health care was reported by 93% of the sample; two thirds of those identified one health care provider. One source of care or one provider was associated with variables such as young age at placement and medical assistance insurance. Children who did not have a single source of care were more likely to have unmet health needs (87% vs 61%, P P Conclusions: Children in kinship care had good access to health care, but the level of unmet health needs was high. Children who did not have a single source of health care were more likely to have unmet health needs, especially unmet mental health needs. These findings have implications for future health care planning for children in out-of-home care. (Arch Pediatr Adolesc Med. 1995;149:882-886)