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Ashaba S, Baguma C, Tushemereirwe P, Nansera D, Maling S, Tsai AC, Zanoni BC. A qualitative analysis of self-management needs of adolescents and young adults living with perinatally acquired HIV in rural, southwestern Uganda. PLOS Glob Public Health 2024; 4:e0003037. [PMID: 38498515 PMCID: PMC10947701 DOI: 10.1371/journal.pgph.0003037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 02/25/2024] [Indexed: 03/20/2024]
Abstract
The number of adolescents living with HIV remains high in sub-Saharan Africa with poorer HIV treatment outcomes among adolescents and young adults compared to individuals in other age groups. For adolescents and young adults living with perinatally acquired HIV (AYLPHIV), the transition from pediatric to adult HIV care is a particularly high-risk period. We conducted a qualitative study to understand self-management needs of AYLPHIV in rural, southwestern Uganda as they prepare to transition to adult HIV care in order to inform relevant interventions that can enable AYLPHIV acquire the necessary skills to manage their illness as they age into adulthood. We conducted 60 in-depth interviews with AYLPHIV (n = 30), caregivers (n = 20) and health care providers (n = 10) from the HIV clinic at Mbarara Regional Referral Hospital. We used an interview guide that focused on perceptions about transition to adult HIV care, challenges with transitioning, navigating HIV care, and self-management needs for AYLPHIV (from the perspectives of AYLPHIV, their caregivers, and health care providers). We used thematic analysis to identify themes related to AYLPHIV's self-management skills. We identified several self-management needs that we grouped under two major themes; social support and empowerment for AYLPHIV to assume responsibility for their own health and to navigate adult HIV care independently. The sub-themes under social support were information support, instrumental support, and emotional support as the sub themes while sub-themes under empowerment included self-advocacy skills, interpersonal skills, self-care skills, and disclosure skills. Taken together, these findings indicate that AYLPHIV need to be supported and empowered to maximize their chances of successfully transitioning to adult HIV care. Support comes from peers and caregivers. AYLPHIV require knowledge about their HIV status and empowerment with different skills including: self-advocacy skills, interpersonal skills, self-care skills, and HIV status disclosure skills, in order to assume responsibilities related to independent HIV care.
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Affiliation(s)
- Scholastic Ashaba
- Department of Psychiatry Mbarara University of Science and Technology, Mbarara, Uganda
| | - Charles Baguma
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Patricia Tushemereirwe
- Global Health Collaborative, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Denis Nansera
- Department of Pediatrics, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Samuel Maling
- Department of Psychiatry Mbarara University of Science and Technology, Mbarara, Uganda
| | - Alexander C. Tsai
- Department of Psychiatry Mbarara University of Science and Technology, Mbarara, Uganda
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Brian C. Zanoni
- Division of Infectious Disease, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Pediatric Infectious Diseases, Children’s Healthcare of Atlanta, Atlanta, Georgia, United States of America
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, United States of America
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Goldstein MH, Moore S, Mohamed M, Byrd R, Curtis MG, Rice WS, Camacho-Gonzalez A, Zanoni BC, Hussen SA. A qualitative analysis examining intersectional stigma among young adults living with HIV in Atlanta, Georgia. PLoS One 2023; 18:e0289821. [PMID: 37561729 PMCID: PMC10414665 DOI: 10.1371/journal.pone.0289821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 07/27/2023] [Indexed: 08/12/2023] Open
Abstract
HIV-related stigma is a barrier to engagement in care for young adults living with HIV. Other intersecting forms of stigma (e.g., racism, sexism, homophobia), may worsen HIV-related stigma and impact engagement in care. From November 2020 to February 2021, we conducted 20 in-depth qualitative interviews among young adults living with HIV attending a large, comprehensive HIV care center in Atlanta, Georgia. Semi-structured interview guides based on Earnshaw and Chaudoir's HIV Stigma Framework and the theory of intersectionality facilitated discussion around experiences with various forms of stigma and its possible influence on healthcare engagement. Using the social-ecological model, we used thematic analysis to contextualize how young adults living with HIV experienced intersectional stigma and enacted, anticipated, and internalized HIV stigma in both healthcare and non-healthcare settings. Most participants identified as male, Black/African American, and gay. Participants described stigma at intrapersonal, interpersonal, clinic, and community levels. Intrapersonal stigma was associated with delayed care seeking, isolation, and fear of disclosure. Interpersonal stigma included discrimination from family and friends and avoidance of close relationships to elude disclosure. At the clinic level, stigma included negative experiences with staff in HIV and non-HIV healthcare settings, which contributed to decreased engagement in care. Stigma in the community included differential treatment from employers, community leaders, and religious community and was associated with feelings of helplessness related to current societal inequalities. Coping/motivating mechanisms for stigma included prioritizing health, eliciting support from the medical care team and peers. Our findings show different intersecting stigmas are barriers to healthcare at multiple levels for young adults living with HIV, potentially exacerbating existing health and social disparities. To improve engagement in care among young adults living with HIV, future interventions should address the different mechanisms of stigma at community, clinic, interpersonal and intrapersonal levels by enhancing social support and improving healthcare structural competency.
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Affiliation(s)
- Madeleine H. Goldstein
- School of Medicine, Emory University, Atlanta, GA, United States of America
- Children’s Healthcare of Atlanta, Atlanta, GA, United States of America
| | - Shamia Moore
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Munira Mohamed
- College of Arts and Sciences, Emory University, Atlanta, GA, United States of America
| | - Rosalind Byrd
- School of Medicine, Emory University, Atlanta, GA, United States of America
| | - Michael G. Curtis
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Whitney S. Rice
- Department of Behavioral, Social and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Andres Camacho-Gonzalez
- School of Medicine, Emory University, Atlanta, GA, United States of America
- Children’s Healthcare of Atlanta, Atlanta, GA, United States of America
| | - Brian C. Zanoni
- School of Medicine, Emory University, Atlanta, GA, United States of America
- Children’s Healthcare of Atlanta, Atlanta, GA, United States of America
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
| | - Sophia A. Hussen
- School of Medicine, Emory University, Atlanta, GA, United States of America
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, United States of America
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Kirabira J, Ashaba S, Favina A, Maling S, Nansera D, Zanoni BC. Intrapersonal predictors of internalized stigma among school going adolescents living with HIV in southwestern Uganda. PSYCHOL HEALTH MED 2023; 28:2300-2314. [PMID: 37005735 PMCID: PMC10524164 DOI: 10.1080/13548506.2023.2198244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 03/27/2023] [Indexed: 04/04/2023]
Abstract
We assessed the association between internalized HIV stigma, resilience, health locus of control, coping self-efficacy and empowerment among adolescents living with HIV in Uganda. We conducted a cross-sectional study between August and October 2020 among 173 adolescents aged 13-18 years attending Mbarara Regional Referral Hospital's HIV clinic. We used linear regression to determine the association between HIV stigma and intrapersonal factors adjusting for sociodemographic characteristics. The median age of the participants was 16 (IQR 3) years. There was a negative correlation between HIV stigma and resilience (β= -0.03, p < 0.001), internal health locus of control (β= -0.095, p < 0.001) and coping self-efficacy (β= -0.02, p < 0.001), while empowerment was positively correlated (β = 0.07, p < 0.001) with HIV stigma. After adjusting for the intrapersonal factors (resilience, health locus of control, coping self-efficacy and empowerment) and socio-demographic characteristics (education level and boarding school), only internal health locus of control (β=-0.044, p = 0.016) and coping self-efficacy (β=-0.015, p < 0.001) remained significantly correlated with HIV stigma. The findings suggest that interventions focusing on intrapersonal factors such as internal locus of control, empowerment and resilience may contribute towards reduction of HIV stigma among adolescents in boarding schools.
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Affiliation(s)
- Joseph Kirabira
- Department of Psychiatry, Busitema University Faculty of Health Sciences, Mbale, Uganda
| | - Scholastic Ashaba
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Alain Favina
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Samuel Maling
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Denis Nansera
- Department of Psychiatry, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Brian C Zanoni
- Departments of Medicine and Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
- Department of Infectious Diseases, Children's Healthcare of Atlanta, Atlanta, GA, USA
- Department of Global Health, Emory University Rollins School of Public Health, Atlanta, GA, USA
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Fomo MF, Newman J, Sibaya T, Ndlela N, Hussen S, Archary M, Zanoni BC. A qualitative assessment of the perceived acceptability and feasibility of eHARTS, a mobile application for transition readiness assessment for adolescents living with HIV in South Africa. PLOS Digit Health 2023; 2:e0000272. [PMID: 37327198 DOI: 10.1371/journal.pdig.0000272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 05/08/2023] [Indexed: 06/18/2023]
Abstract
South Africa has the highest burden of adolescents living with HIV (ALHIV) in the world. The transition from pediatric to adult centered HIV care is a vulnerable period during which many clinical outcomes of ALHIV suffer. Transition readiness assessments may help ALHIV transition from pediatric to adult care to improve their health outcomes. Here, we evaluated the perceived acceptability and feasibility of a mobile health (mHealth) application, eHARTS, to determine transition readiness for ALHIV in South Africa. We conducted in-depth interviews with adolescents (n = 15) and healthcare providers (n = 15) at three government-supported hospitals in KwaZulu-Natal, South Africa. We used a semi-structured interview guide comprising of open-ended questions based on the unified theory of acceptance and use of technology. We did a thematic analysis of the data using an iterative, team-based coding approach to develop themes that were representative of the participants' perspectives on the acceptability and feasibility of eHARTS. We found that most participants found eHARTS to be acceptable because of its simplicity and lack of stigma. Participants believed eHARTS was feasible as it could easily be administered within a hospital setting and integrated into regular clinic activity without disrupting patient care. Additionally, eHARTS was found to have great utility for adolescents and healthcare providers. Clinicians saw it as a valuable tool to engage adolescents and prepare them for transition. Despite concerns that eHARTS may give adolescents a wrong impression about immediate transition, participants suggested that eHARTS be framed in an empowering way as they prepare for transition to adult care. Our data showed that eHARTS is a simple, mobile transition assessment tool with perceived acceptability and feasibility for use in HIV clinics in South Africa for ALHIV. It is particularly useful for ALHIV and transitioning to adult care as it can help identify gaps in readiness for transition.
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Affiliation(s)
- Messaline F Fomo
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
| | - John Newman
- Department of Medicine and Pediatric Infectious Diseases, Emory University, Georgia, United States of America
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Thobekile Sibaya
- Department of Pediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Nompumelelo Ndlela
- Department of Pediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Sophia Hussen
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Medicine and Pediatric Infectious Diseases, Emory University, Georgia, United States of America
| | - Moherndran Archary
- Department of Pediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, KwaZulu Natal, South Africa
| | - Brian C Zanoni
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, United States of America
- Department of Medicine and Pediatric Infectious Diseases, Emory University, Georgia, United States of America
- Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
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Ahmed CV, Brooks MJ, DeLong SM, Zanoni BC, Njuguna I, Beima-Sofie K, Dow DE, Shayo A, Schreibman A, Chapman J, Chen L, Mehta S, Mbizvo MT, Lowenthal ED. Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network. AIDS Behav 2023; 27:84-93. [PMID: 36574183 PMCID: PMC9792928 DOI: 10.1007/s10461-022-03959-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2022] [Indexed: 12/28/2022]
Abstract
We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.
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Affiliation(s)
- Charisse V Ahmed
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Merrian J Brooks
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Children's Hospital of Philadelphia Global Health Center, Philadelphia, PA, USA
| | - Stephanie M DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Brian C Zanoni
- Departments of Medicine and Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Irene Njuguna
- Kenyatta National Hospital, Research and Programs, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - Dorothy E Dow
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
- Duke Global Health Institute, Durham, NC, USA
| | - Aisa Shayo
- Kilimanjaro Christian Medical Centre, Moshi, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | | | - Jennifer Chapman
- Children's Hospital of Philadelphia Global Health Center, Philadelphia, PA, USA
| | - Lydia Chen
- University of Pennsylvania, Philadelphia, PA, USA
| | - Shreya Mehta
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Elizabeth D Lowenthal
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- Children's Hospital of Philadelphia Global Health Center, Philadelphia, PA, USA.
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
- CHOP Roberts Center for Pediatric Research, 734 Schuylkill Ave, 19146, Philadelphia, PA, USA.
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Hussen SA, Doraivelu K, Goldstein MH, Shenvi N, Easley KA, Zanoni BC, Camacho-González A, del Río C. Human Immunodeficiency Virus (HIV) Care Continuum Outcomes After Transition to Adult Care Among a Prospective Cohort of Youth With HIV in Atlanta, Georgia. Clin Infect Dis 2023; 76:1218-1224. [PMID: 36409586 PMCID: PMC10319754 DOI: 10.1093/cid/ciac904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Healthcare transition from pediatric to adult-oriented clinical settings is often viewed as a high-risk time for care disengagement. However, there is a paucity of prospective, longitudinal research documenting human immunodeficiency virus (HIV) care outcomes after healthcare transition. METHODS We conducted a prospective, observational cohort study of healthcare transition among youth enrolled at an HIV care center in Atlanta, Georgia. Pediatric clinic patients (average age, 24 years) were enrolled up to 3 months before the expected transition and were followed up to determine linkage, retention, and viral suppression in adult care through electronic medical record abstractions at the baseline and at 6, 12, 18, and 24 months. RESULTS The majority of our cohort (n = 70) was male (88.6%) and black (92.9%) and acquired HIV horizontally (80%). Most of our cohort was linked to adult care by 12 months (84%) after enrollment. Of those who linked to adult care by 12 months, retention rates were 86% (95% confidence interval, 78%-94%) at 6 months, 76% (66%-86%) at 12 months, and 66% (55%-78%) at 18 and 24 months. Once in adult care, the proportion with viral suppression was stable (73% at baseline and 74%, 77%, 67%, and 78% at 6, 12, 18, and 24 months, respectively). CONCLUSIONS Although most youth successfully linked to adult care, retention rates decreased over the 24-month follow-up period. Rates of viral suppression were stable for those who remained in care. Strategies to support retention in adult care will be critical to optimizing this transition for youth with HIV.
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Affiliation(s)
- Sophia A Hussen
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kamini Doraivelu
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Madeleine H Goldstein
- Department of Pediatrics, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Neeta Shenvi
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Kirk A Easley
- Department of Biostatistics and Bioinformatics, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
| | - Brian C Zanoni
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Department of Pediatrics, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrés Camacho-González
- Department of Pediatrics, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carlos del Río
- Hubert Department of Global Health, Emory University Rollins School of Public Health, Atlanta, Georgia, USA
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia, USA
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Ashaba S, Zanoni BC, Baguma C, Tushemereirwe P, Nuwagaba G, Kirabira J, Nansera D, Maling S, Tsai AC. Challenges and Fears of Adolescents and Young Adults Living with HIV Facing Transition to Adult HIV Care. AIDS Behav 2023; 27:1189-1198. [PMID: 36129557 PMCID: PMC10027623 DOI: 10.1007/s10461-022-03856-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2022] [Indexed: 11/01/2022]
Abstract
Adolescents and young adults living with perinatally-acquired HIV (AYLPHIV) have poor outcomes along each step of the HIV care continuum due to challenges in seeking care and advocating for themselves. The transition from paediatric to adult HIV care is a particularly high-risk period for AYLPHIV in rural Uganda. We conducted in-depth interviews with AYLPHIV (n = 30), caregivers (n = 10), and healthcare providers (n = 10) to understand challenges facing AYLPHIV during the transition from paediatric to adult HIV care. Themes were identified by thematic content analysis. Transition-related challenges and fears included difficulty navigating the adult HIV clinic; loss of informational support; long wait times at the adult HIV clinic; lack of privacy, and fear of HIV status disclosure and stigma; and loss of support from caregivers, and health care providers. Before transitioning to adult HIV care, AYLPHIV should be adequately prepared and given appropriate information to help them navigate adult HIV care.
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Affiliation(s)
- Scholastic Ashaba
- Mbarara University of Science and Technology, Plot 8-18, P. O.BOX 1410, Mbarara, Uganda.
| | - Brian C Zanoni
- Emory University School of Medicine, Atlanta, GA, USA
- Children's Healthcare of Atlanta, Atlanta, USA
- Emory University's Rollins School of Public Health, Atlanta, GA, USA
| | - Charles Baguma
- Mbarara University of Science and Technology, Plot 8-18, P. O.BOX 1410, Mbarara, Uganda
| | | | - Gabriel Nuwagaba
- Mbarara University of Science and Technology, Plot 8-18, P. O.BOX 1410, Mbarara, Uganda
| | | | - Denis Nansera
- Mbarara University of Science and Technology, Plot 8-18, P. O.BOX 1410, Mbarara, Uganda
| | - Samuel Maling
- Mbarara University of Science and Technology, Plot 8-18, P. O.BOX 1410, Mbarara, Uganda
| | - Alexander C Tsai
- Mbarara University of Science and Technology, Plot 8-18, P. O.BOX 1410, Mbarara, Uganda
- Center for Global Health and Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Khosravi D, Soloff H, Langsjoen RM, Bombin A, Kelley CF, Ray SM, Gunthel CJ, Zanoni BC, Nguyen PV, Waggoner JJ, Wang YF, Cantos VD, Piantadosi A. Severe Acute Respiratory Syndrome Coronavirus 2 Evolution and Escape From Combination Monoclonal Antibody Treatment in a Person With HIV. Open Forum Infect Dis 2023; 10:ofad054. [PMID: 36820315 PMCID: PMC9938522 DOI: 10.1093/ofid/ofad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/02/2023] [Indexed: 02/05/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) escape from combination monoclonal antibody treatment is rarely reported. We describe an immunocompromised individual with human immunodeficiency virus and persistent SARS-CoV-2 infection in whom substantial SARS-CoV-2 evolution occurred, including the emergence of 2 mutations associated with escape from the monoclonal antibody cocktail received.
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Affiliation(s)
- Dara Khosravi
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | - Rose M Langsjoen
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrei Bombin
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Colleen F Kelley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Susan M Ray
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Clifford J Gunthel
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian C Zanoni
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA,Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Phuong-Vi Nguyen
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jesse J Waggoner
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Yun F Wang
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Valeria D Cantos
- Correspondence: Anne Piantadosi, MD, PhD, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA 30322 (); Valeria D. Cantos, 46 Armstrong St SE, Atlanta, GA; ()
| | - Anne Piantadosi
- Correspondence: Anne Piantadosi, MD, PhD, Emory University School of Medicine, 101 Woodruff Circle, Atlanta, GA 30322 (); Valeria D. Cantos, 46 Armstrong St SE, Atlanta, GA; ()
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Zanoni BC, Milford C, Sithole K, Mosery N, Wilson M, Bosman S, Smit J. High risk injection drug use and uptake of HIV prevention and treatment services among people who inject drugs in KwaZulu-Natal, South Africa. medRxiv 2023:2023.01.16.23284613. [PMID: 36711846 PMCID: PMC9882559 DOI: 10.1101/2023.01.16.23284613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The use of injection drugs in South Africa is increasing. HIV prevention, treatment and addiction services for people who inject drugs (PWID) in South Africa are not well documented. We conducted a mixed-methods study to understand current drug use practices and access to HIV prevention and treatment services for PWID in KwaZulu-Natal, South Africa. We used respondent-driven sampling to recruit 45 people who reported injecting opiates within the past 6 months from Durban, KwaZulu-Natal, South Africa. We found high rates of practices that increase HIV/viral hepatitis risk including the use of shared needles (43%) and direct blood injections (bluetoothing) (18%). Despite 35% of participants living with HIV, only 40% accessed antiretroviral therapy within the past year, and one accessed PrEP. None of the participants reported ever testing for Hepatitis C.
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Affiliation(s)
- Brian C. Zanoni
- Emory University, Atlanta, Georgia, United States of America,Children’s Healthcare of Atlanta, Atlanta, Georgia, United States of America,Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Cecilia Milford
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Kedibone Sithole
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Nzwakie Mosery
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
| | - Michael Wilson
- Advance Access & Delivery, Durban, South Africa,Department of Health Behaviour, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Shannon Bosman
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Jennifer Smit
- Wits MRU (MatCH Research Unit), Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of the Witwatersrand, Durban, South Africa
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Zanoni BC, Milford C, Sithole K, Mosery N, Wilson M, Bosman S, Smit J. High risk injection drug use and uptake of HIV prevention and treatment services among people who inject drugs in KwaZulu-Natal, South Africa. PLoS One 2023; 18:e0281030. [PMID: 37172026 PMCID: PMC10180682 DOI: 10.1371/journal.pone.0281030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 04/12/2023] [Indexed: 05/14/2023] Open
Abstract
We conducted a mixed-methods study to understand current drug use practices and access to healthcare services for people who use injection drugs in KwaZulu-Natal, South Africa. We used respondent-driven sampling to recruit 45 people who used injection drugs within the past 6 months from KwaZulu-Natal, South Africa. We found high rates of practices that increase HIV/viral hepatitis risk including the use of shared needles (43%) and direct blood injections (bluetoothing) (18%). Despite 35% living with HIV, only 40% accessed antiretroviral therapy within the past year, and one accessed PrEP. None of the participants ever tested for Hepatitis C.
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Affiliation(s)
- Brian C Zanoni
- Emory University, Atlanta, Georgia, United States of America
- Children's Healthcare of Atlanta, Atlanta, Georgia, United States of America
- Rollins School of Public Health, Atlanta, Georgia, United States of America
| | - Cecilia Milford
- Faculty of Health Sciences, MRU (MatCH Research Unit), School of Obstetrics and Gynecology, University of the Witwatersrand, Durban, South Africa
| | - Kedibone Sithole
- Faculty of Health Sciences, MRU (MatCH Research Unit), School of Obstetrics and Gynecology, University of the Witwatersrand, Durban, South Africa
| | - Nzwakie Mosery
- Faculty of Health Sciences, MRU (MatCH Research Unit), School of Obstetrics and Gynecology, University of the Witwatersrand, Durban, South Africa
| | - Michael Wilson
- Advance Access & Delivery, Durban, South Africa
- Department of Health Behaviour, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Shannon Bosman
- Centre for Community Based Research, Human Sciences Research Council, Pietermaritzburg, South Africa
| | - Jennifer Smit
- Faculty of Health Sciences, MRU (MatCH Research Unit), School of Obstetrics and Gynecology, University of the Witwatersrand, Durban, South Africa
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11
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Bergam S, Sibaya T, Ndlela N, Kuzwayo M, Fomo M, Goldstein MH, Marconi VC, Haberer JE, Archary M, Zanoni BC. "I am not shy anymore": A qualitative study of the role of an interactive mHealth intervention on sexual health knowledge, attitudes, and behaviors of South African adolescents with perinatal HIV. Reprod Health 2022; 19:217. [PMID: 36457044 PMCID: PMC9713189 DOI: 10.1186/s12978-022-01519-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 10/21/2022] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND South Africa has one of the highest burdens of adolescents with perinatally-acquired HIV (APHIV) in the world. APHIV in South Africa have limited access to sexual and reproductive health (SRH) education and services specific to their HIV status. When lacking comprehensive SRH education, APHIV are prone to sexual risk behaviors that can lead to unintended pregnancy, sexually transmitted infections, and HIV transmission. The use of mHealth interventions has been shown to deliver information, foster social support, and improve decision-making skills. In this study, we evaluate how an mHealth intervention influences sexual health knowledge and behaviors in APHIV. METHODS We purposively enrolled adolescents from the intervention arm of a randomized clinical trial assessing a multi-module, moderated WhatsApp-based intervention-Interactive Transition Support for Adolescents Living with HIV (InTSHA)-within a government supported clinic in KwaMashu, an urban township of KwaZulu-Natal, South Africa. We conducted in-depth interviews based on World Health Organization guidelines for asking adolescents about SRH. We thematically analyzed data through an iterative, team-based coding approach combining deductive and inductive elements to contextualize SRH attitudes, knowledge, and behaviors before and after receiving the InTSHA intervention. RESULTS Of the 21 participants, 13 (61.9%) were female and the mean age was 16.6 years. Most participants reported first learning about SRH as young teenagers in school through non-targeted and negative ways, seeking clarification through peers and the internet rather than clinicians or caregivers. Participants reported that InTSHA provided a holistic perspective on relationships, gender, and sexuality specific to growing up with HIV in South Africa. They praised the ability to give and receive information from peers in a moderated setting through the mHealth intervention, building their confidence, decision-making skills, and communication with partners and caregivers throughout their everyday lives. Despite reporting some technological challenges, adolescents agreed that InTSHA was convenient, confidential, and user-friendly. CONCLUSIONS South African APHIV receive incomplete and conflicting sexual education from peers, caregivers, teachers, and technology that can be supplemented by mHealth curricula targeted for the unique needs of APHIV. Future, scaled-up mHealth interventions can lower SRH stigma by expanding access to sexual education and peer support, supplementing adolescents' existing SRH education.
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Affiliation(s)
- Scarlett Bergam
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa ,George Washington School of Medicine and Health Sciences, Washington, DC USA
| | - Thobekile Sibaya
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Nompumelelo Ndlela
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Mpume Kuzwayo
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Messaline Fomo
- grid.189967.80000 0001 0941 6502Department of Global Health, Emory University’s Rollins School of Public Health, Atlanta, GA USA
| | | | - Vincent C. Marconi
- grid.189967.80000 0001 0941 6502Departments of Medicine and Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA USA ,grid.189967.80000 0001 0941 6502Department of Global Health, Emory University’s Rollins School of Public Health, Atlanta, GA USA
| | - Jessica E. Haberer
- grid.32224.350000 0004 0386 9924Massachusetts General Hospital, Boston, MA USA ,grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Moherndran Archary
- grid.16463.360000 0001 0723 4123Department of Paediatrics, Nelson Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa
| | - Brian C. Zanoni
- grid.189967.80000 0001 0941 6502Departments of Medicine and Pediatric Infectious Diseases, Emory University School of Medicine, Atlanta, GA USA ,grid.189967.80000 0001 0941 6502Department of Global Health, Emory University’s Rollins School of Public Health, Atlanta, GA USA ,grid.428158.20000 0004 0371 6071Children’s Healthcare of Atlanta, Atlanta, GA USA
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12
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Goldstein M, Archary M, Adong J, Haberer JE, Kuhns LM, Kurth A, Ronen K, Lightfoot M, Inwani I, John-Stewart G, Garofalo R, Zanoni BC. Systematic Review of mHealth Interventions for Adolescent and Young Adult HIV Prevention and the Adolescent HIV Continuum of Care in Low to Middle Income Countries. AIDS Behav 2022; 27:94-115. [PMID: 36322217 PMCID: PMC9629200 DOI: 10.1007/s10461-022-03840-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/27/2022] [Indexed: 11/06/2022]
Abstract
Adolescents and young adults (AYA) in low to middle income countries (LMIC) have poorer outcomes along each step in the HIV continuum of prevention and care compared to younger children or older adults. The use of mHealth technology provides a potentially promising implementation strategy for interventions to remedy these disparities. We therefore conducted a systematic review of the English literature and conference proceedings from January 1, 2000 to April 1, 2021 evaluating mHealth interventions targeting AYA along each step of the HIV continuum of care in LMIC. We identified 27 mHealth interventions across the HIV continuum, with no interventions addressing transition from pediatric to adult care. The majority of studies were single arm, uncontrolled or underpowered, with few randomized trials resulting in mixed and inconclusive outcomes. mHealth interventions have potential to remedy disparities along the HIV continuum of care for AYA in LMIC but larger, powered randomized trials are needed.
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Affiliation(s)
- Madeleine Goldstein
- Emory University, Atlanta, GA, United States of America
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
- King Edward VIII Hospital, Durban, South Africa
| | - Julian Adong
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, MA, United States of America
- Harvard Medical School, Boston, MA, United States of America
| | - Lisa M Kuhns
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Keshet Ronen
- University of Washington, Seattle, WA, United States of America
| | - Marguerita Lightfoot
- Center for AIDS Prevention Studies and UCSF Prevention Research Center, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Robert Garofalo
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Brian C Zanoni
- Emory University, Atlanta, GA, United States of America.
- Children's Healthcare of Atlanta, Atlanta, GA, United States of America.
- Rollins School of Public Health, Atlanta, GA, USA.
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13
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Zanoni BC, Archary M, Sibaya T, Goldstein M, Bergam S, Denton D, Cordero V, Peng C, Psaros C, Marconi VC, Haberer JE. Mobile Phone-Based Intervention Among Adolescents Living With Perinatally Acquired HIV Transitioning from Pediatric to Adult Care: Protocol for the Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA) Study. JMIR Res Protoc 2022; 11:e35455. [PMID: 35060907 PMCID: PMC8817214 DOI: 10.2196/35455] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Revised: 12/08/2021] [Accepted: 12/15/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Adolescents living with perinatally acquired HIV often have poor retention in care and viral suppression during the transition from pediatric to adult-based care. OBJECTIVE The aim of this study is to evaluate a mobile phone-based intervention, Interactive Transition Support for Adolescents Living With HIV using Social Media (InTSHA), among adolescents living with perinatally acquired HIV as they transition from pediatric to adult care in South Africa. METHODS InTSHA uses encrypted, closed group chats delivered via WhatsApp (Meta Platforms Inc) to develop peer support and improve communication between adolescents, their caregivers, and health care providers. The intervention is based on formative work with adolescents, caregivers, and health care providers and builds on several existing adolescent support programs as well as the Social-ecological Model of Adolescent and Young Adult Readiness for Transition (SMART). The final InTSHA intervention involves 10 modules conducted weekly through moderated WhatsApp group chats with adolescents and separately with their caregivers. We will randomly assign 80 South African adolescents living with perinatally acquired HIV who are aware of their HIV status and aged between 15 and 19 years to receive either the intervention (n=40) or standard of care (n=40). RESULTS We will measure acceptability of the intervention as the primary outcome and evaluate feasibility and preliminary effectiveness for retention in care and viral suppression after completion of the intervention and at least 6 months after randomization. In addition, we will measure secondary outcomes evaluating the impact of the InTSHA intervention on peer support, self-esteem, depression, stigma, sexual education, connection to health care providers, and transition readiness. Enrollment began on April 15, 2021. As of December 31, 2021 a total of 78 out of expected 80 participants have been enrolled. CONCLUSIONS If successful, the intervention will be evaluated in a fully powered randomized controlled trial with a larger number of adolescents from urban and rural populations to further evaluate the generalizability of InTSHA. TRIAL REGISTRATION ClinicalTrials.gov NCT03624413; https://clinicaltrials.gov/ct2/show/NCT03624413. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/35455.
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Affiliation(s)
- Brian C Zanoni
- School of Medicine, Emory University, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Moherndran Archary
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- King Edward VIII Hospital, Durban, South Africa
| | - Thobekile Sibaya
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Madeleine Goldstein
- School of Medicine, Emory University, Atlanta, GA, United States
- Children's Healthcare of Atlanta, Atlanta, GA, United States
| | - Scarlett Bergam
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
- King Edward VIII Hospital, Durban, South Africa
| | - David Denton
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Vincente Cordero
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Cynthia Peng
- School of Medicine, Emory University, Atlanta, GA, United States
| | - Christina Psaros
- Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Harvard University, Boston, MA, United States
| | - Vincent C Marconi
- School of Medicine, Emory University, Atlanta, GA, United States
- Rollins School of Public Health, Emory University, Atlanta, GA, United States
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, MA, United States
- Harvard Medical School, Harvard University, Boston, MA, United States
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Dube-Pule A, Zanoni BC, Connolly C, Shabangu M, Archary M. Evaluation of an SMS-based mHealth intervention to enhance early infant diagnosis follow-up testing and assessment of postnatal prophylaxis. South Afr J HIV Med 2021; 22:1301. [PMID: 34917408 PMCID: PMC8661286 DOI: 10.4102/sajhivmed.v22i1.1301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 10/03/2021] [Indexed: 11/18/2022] Open
Abstract
Background Adherence to infant antiretroviral (ARV) postnatal prophylaxis and early infant diagnosis (EID) uptake is low in Africa. Promoting EID and adherence are necessary for this age group. Objectives We evaluated an SMS-based mobile health (mHealth) intervention to enhance adherence to ARV prophylaxis and knowledge of EID and prevention of mother-to-child transmission (PMTCT) among high-risk and low-risk mother–infant pairs. Method Two hundred and fifty-one mothers were recruited from King Edward VIII Hospital between December 2018 and October 2019. Participant information was captured, and SMS reminders were sent postnatally to promote immunisation attendance. Follow-up HIV polymerase chain reaction (PCR) test results were reviewed, and telephonic interviews were utilised for qualitative data. Results In all, 73.3% of infants had HIV PCR tests performed at 10 weeks. This high rate could be attributed to the mHealth intervention as this is considerably higher than other national studies, though not statistically significant compared to rates reported in the district at the same time. Factors that have impacted follow-up EID rates include poor maternal knowledge of EID time points and inadequate implementation of national PMTCT protocols. High-risk mothers were younger, commenced antenatal clinic visit later, were less knowledgeable on prophylaxis and have lower-birthweight infants than lower-risk mothers. Conclusion mHealth can play an important role in improving EID by increasing maternal knowledge. Further studies should focus on whether maternal education over an mHealth platform can increase knowledge on PMTCT and subsequently increase EID.
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Affiliation(s)
- Anele Dube-Pule
- Department of Paediatrics and Child Health, Faculty of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - Brian C Zanoni
- Department of Pediatrics, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, United States of America
| | - Cathy Connolly
- School of Public Health, University of KwaZulu-Natal, Durban, South Africa
| | - Majahonkhe Shabangu
- Sawubona Health Inc., Malden, Massachusetts, United States of America.,Department of Human Biology, Division of Biomedical Engineering, University of Cape Town, Cape Town, South Africa
| | - Moherndran Archary
- Department of Paediatrics and Child Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.,Department of Paediatrics, King Edward VIII Hospital, Durban, South Africa
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15
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Zanoni BC, Archary M, Sibaya T, Musinguzi N, Kelley ME, McManus S, Haberer JE. Development and validation of the HIV adolescent readiness for transition scale (HARTS) in South Africa. J Int AIDS Soc 2021; 24:e25767. [PMID: 34235876 PMCID: PMC8264413 DOI: 10.1002/jia2.25767] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 04/30/2021] [Accepted: 06/11/2021] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Adolescents living with perinatally acquired HIV have low rates of retention in care and viral suppression after the transition from paediatric to adult care. In this study, we developed and validated a tool to identify adolescent transition readiness. METHODS We developed the HIV Adolescent Readiness for Transition Scale (HARTS) from June 2016 to May 2019 by iteratively adapting existing transition readiness scales for other chronic illnesses by conducting focus groups with 11 healthcare providers and 20 adolescents in South Africa. We administered a preliminary questionnaire to 131 adolescents to determine psychometric properties and assess test-retest variability. We used confirmatory factor analysis to verify the proposed scale structure using the underlying variable approach. We correlated responses to self-described transition readiness and age using linear regression. We subsequently validated the scale by prospectively administering it to 199 adolescents in a second South African setting before their transition. We then used multivariable logistic regression to assess the effects of the HARTS and relevant socio-behavioural covariates on viral suppression one year after transition. RESULTS We identified four domains relevant to transition readiness: disclosure, health navigation, self-advocacy and health literacy. Fifteen questions with a significant factor loading of 0.3 to 0.9 were identified. No significant test-retest variability was seen among 10% of participants. Positive correlations with self-described transition readiness were significant with the overall HARTS and domains of health navigation, self-advocacy and health literacy. In the prospective analysis, for adolescents not using drugs, each 10-point increase in the HARTS was associated with 0.62 odds of viral failure (95% CI 0.45 to 0.86; p = 0.004). The individual domains of self-advocacy (AOR 0.56; 95% CI 0.33 to 0.94; p = 0.029), disclosure (AOR 0.02; 95% CI 0.01 to 0.25; p = 0.002), health navigation (AOR 0.51; 95%CI 0.25 to 1.02; p = 0.056) and health literacy (AOR 0.37; 95% CI 0.10 to 1.30; p = 0.121) were associated with viral failure adjusting for age at antiretroviral therapy initiation, ART regimen, sex, disclosure status, and alcohol use in both analyses. CONCLUSIONS The HARTS is a validated scale that can be used to identify which adolescents may require additional interventions prior to transitioning to adult care to improve viral suppression after transition.
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Affiliation(s)
- Brian C Zanoni
- Emory UniversityAtlantaGAUSA
- Children’s Healthcare of AtlantaAtlantaGAUSA
| | - Moherndran Archary
- University of KwaZulu‐Natal Nelson Mandela School of MedicineDurbanSouth Africa
- King Edward VIII HospitalDurbanSouth Africa
| | - Thobekile Sibaya
- University of KwaZulu‐Natal Nelson Mandela School of MedicineDurbanSouth Africa
| | - Nicholas Musinguzi
- Global Health CollaborativeUniversity of Science and TechnologyMbararaUganda
| | - Mary E Kelley
- Emory UniversityAtlantaGAUSA
- Rollins School of Public healthAtlantaGAUSA
| | - Shauna McManus
- Emory UniversityAtlantaGAUSA
- Rollins School of Public healthAtlantaGAUSA
| | - Jessica E Haberer
- Massachusetts General HospitalBostonMAUSA
- Harvard Medical SchoolBostonMAUSA
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Zanoni BC, Haberer JE. The Meaning of "Rapid" Antiretroviral Therapy Initiation for Adolescents With Human Immunodeficiency Virus in Sub-Saharan Africa. J Infect Dis 2021; 222:705-707. [PMID: 31682259 DOI: 10.1093/infdis/jiz548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 10/28/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Brian C Zanoni
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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Zanoni BC, Archary M, Subramony T, Sibaya T, Psaros C, Haberer JE. "It was not okay because you leave your friends behind": A prospective analysis of transition to adult care for adolescents living with perinatally-acquired HIV in South Africa. Vulnerable Child Youth Stud 2021; 16:206-220. [PMID: 34484412 PMCID: PMC8414445 DOI: 10.1080/17450128.2021.1876965] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/06/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine facilitators and barriers to successful transition to adult care for adolescents living with perinatally-acquired HIV in South Africa. METHODS We prospectively enrolled 30 adolescents living with perinatally-acquired HIV after their pediatrician deemed them ready for transition to adult care but prior to their transition. Eighteen months after enrollment, we measured transition status, engagement in care (i.e., viral load within 12 months of transition), and viral suppression (<200 copies/ml). Additionally, we conducted in-depth interviews with adolescents before and after transition to explore facilitators and barriers to successful transition. RESULTS A total of 19/30 (63%) adolescents transitioned to adult care. Of those who transitioned, 11 (58%) were retained in care and 7 (37%) were virally suppressed one year after transition to adult care. Insufficient staff training, lack of availability of pediatric ART formulations in adult clinics, and insufficient clinical monitoring contributed to delayed transition. Rigid clinical scheduling that interfered with school and loss of clinic relationships with peers and clinical staff were major factors in contributing to poor engagement in care after transition. Maturity of the adolescent, reduced distance to clinic, and reduced length of time in the clinic were seen as facilitators to transition to adult care. CONCLUSION Improved preparation for transition by pediatric and adult clinical staff, including restructuring of care delivery, may improve successful transition of adolescents living with perinatally acquired HIV to adult care. Transition readiness assessments are needed to determine optimal timing of transition and which adolescents are ready to transition to adult care.
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Affiliation(s)
- Brian C. Zanoni
- Emory University, Atlanta, Georgia, United States of America
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | | | - Thobekile Sibaya
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | - Christina Psaros
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Jessica E. Haberer
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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18
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Zanoni BC, Archary M, Sibaya T, Musinguzi N, Haberer JE. Transition from pediatric to adult care for adolescents living with HIV in South Africa: A natural experiment and survival analysis. PLoS One 2020; 15:e0240918. [PMID: 33108396 PMCID: PMC7591089 DOI: 10.1371/journal.pone.0240918] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Accepted: 10/05/2020] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To determine rates of retention and viral suppression among adolescents living with perinatally-acquired HIV who remained in pediatric care compared to those who transitioned to adult care. METHODS We evaluated a natural experiment involving adolescents living with perinatally-acquired HIV who were attending a government-supported antiretroviral clinic in KwaZulu-Natal, South Africa. Prior to 2011, all adolescents transitioned to adult care at 12 years of age. Due to a policy change, all adolescents were retained in pediatric care after 2011. We analyzed adolescents two years before and two years after this policy change. Outcomes were retention in care and HIV viral suppression one year after transition to adult care or the 13th birthday if remaining in pediatric care. RESULTS In the natural experiment, 180 adolescents who turned 12 years old between 2011 and 2014 were evaluated; 35 (20%) transitioned to adult care under the old policy and 145 (80%) remained in pediatric care under the new policy. Adolescents who transitioned to the adult clinic had lower rates of retention in care (49%; 17/35) compared to adolescents remaining in the pediatric clinic (92%; 134/145; p<0.001). Retention in care was lower (ARR 0.59; 95%CI 0.43-0.82; p = 0.001) and viral suppression was similar (ARR = 1.06, 95%CI 0.89-1.26; p = 0.53) for adolescents who transitioned to adult care compared to adolescents remaining in pediatric care. CONCLUSION Adolescents living with perinatally-acquired HIV appear to have higher retention in care when cared for in pediatric clinics compared to adult clinics. Longer-term follow-up is needed to fully assess viral suppression.
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Affiliation(s)
- Brian C. Zanoni
- Emory University, Atlanta, Georgia, United States of America
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | - Thobekile Sibaya
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | | | - Jessica E. Haberer
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Zanoni BC, Sibaya T, Cairns C, Haberer JE. Barriers to Retention in Care are Overcome by Adolescent-Friendly Services for Adolescents Living with HIV in South Africa: A Qualitative Analysis. AIDS Behav 2019; 23:957-965. [PMID: 30535836 PMCID: PMC6459720 DOI: 10.1007/s10461-018-2352-6] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
To assess facilitators and barriers to retention in care for adolescents living with HIV, we conducted in-depth, semi-structured interviews with adolescents ages 13 to 24 years who were living with HIV and being cared for in either an adolescent-friendly or standard government-supported clinic in KwaZulu-Natal, South Africa. We used inductive content analysis approach based on grounded theory derived from reviewing, coding, and interpreting data. We interviewed 28 adolescents living with HIV (16 in the adolescent clinic and 12 from the pediatric clinic) and 14 of their caregivers. Barriers to retention in care included having to attend clinic during school hours, fear of disclosure to others, social isolation, and conflict with clinical staff. Facilitators to retention in care seen in the adolescent-friendly services clinic included after school clinic hours, peer support, and connection to the clinical staff. Adolescent-friendly services are facilitators of HIV care and warrant prioritization in treatment programs.
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Affiliation(s)
- Brian C. Zanoni
- Massachusetts General Hospital, Boston, Massachusetts, United States of America,Harvard Medical School, Boston, Massachusetts, United States of America,Corresponding Author: Brian C. Zanoni, MD, MPH, 55 Fruit Street, Cox Building 5 Floor, Boston, MA 02114 USA, , + 1 (857)654 – 4162
| | - Thobekile Sibaya
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | | | - Jessica E. Haberer
- Massachusetts General Hospital, Boston, Massachusetts, United States of America,Harvard Medical School, Boston, Massachusetts, United States of America
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Zanoni BC, Elliott RJ, Neilan AM, Haberer JE. Screening for HIV and linkage to care in adolescents: insights from a systematic review of recent interventions in high- versus low- and middle-income settings. Adolesc Health Med Ther 2018; 9:211-235. [PMID: 30584383 PMCID: PMC6287534 DOI: 10.2147/ahmt.s153204] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction Compared to adults, adolescents and young adults have a higher incidence of HIV infection, yet lower rates of HIV testing. Few evidence-based interventions effectively diagnose new HIV infections among adolescents while successfully providing linkage to care. Methods We conducted a systematic review of recent interventions to increase HIV testing among adolescents and young adults using data retrieved from PubMed and Google Scholar, and using abstracts presented at the International AIDS Society conferences and Conference on Retroviruses and Opportunistic Infections published between January 1, 2015, and April 28, 2018. Results We identified 36 interventions (N=14 in high- income countries and N=22 in low- and middle-income countries) that were published in the literature (N=28) or presented at conferences (N=8). Interventions were categorized as behavioral/educational, alternate venue/self-testing, youth-friendly services, technology/mobile health, incentives, or peer-based/community-based interventions. The studies consisted of randomized controlled trials (RCTs), prospective and retrospective observational studies, and quasi-experimental/pre-post evaluations with variable sample sizes. Study designs, populations, and settings varied. All categories showed some degree of acceptability, yet not all interventions were effective in increasing HIV testing. Effectiveness was seen in more than one RCT involving technology/mobile health (2/3 RCTs) and alternative venue/self-testing (3/3 RCTs) interventions, and only in one RCT each for behavioral interventions, community interventions, and incentives. There were no effective RCTs for adolescent-friendly services. Data were limited on the number of new infections identified and on the methods to increase linkage to care after diagnosis. Conclusion Future studies should include combinations of proven methods for engaging adolescents in HIV testing, while ensuring effective methods of linkage to care.
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Affiliation(s)
- Brian C Zanoni
- Department of Global Health, Massachusetts General Hospital, Boston, MA, USA, .,Department of Medicine, Harvard Medical School, Boston, MA, USA,
| | - Ryan J Elliott
- Premedical Program, Harvard Extension School, Cambridge, MA, USA
| | - Anne M Neilan
- Department of Global Health, Massachusetts General Hospital, Boston, MA, USA, .,Department of Medicine, Harvard Medical School, Boston, MA, USA,
| | - Jessica E Haberer
- Department of Global Health, Massachusetts General Hospital, Boston, MA, USA, .,Department of Medicine, Harvard Medical School, Boston, MA, USA,
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Zanoni BC, Sibaya T, Cairns C, Lammert S, Haberer JE. Higher retention and viral suppression with adolescent-focused HIV clinic in South Africa. PLoS One 2017; 12:e0190260. [PMID: 29287088 PMCID: PMC5747481 DOI: 10.1371/journal.pone.0190260] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 11/19/2017] [Indexed: 12/26/2022] Open
Abstract
Objective To determine retention in care and virologic suppression among HIV-infected adolescents and young adults attending an adolescent-friendly clinic compared to those attending the standard pediatric clinic at the same site. Design Retrospective cohort analysis. Setting Government supported, hospital-based antiretroviral clinic in KwaZulu-Natal, South Africa. Participants Two hundred forty-one perinatally HIV-infected adolescents and young adults aged 13 to 24 years attending an adolescent-friendly clinic or the standard pediatric clinic from April 2007 to November 2015. Intervention Attendance in an adolescent-friendly clinic compared to a standard pediatric clinic. Outcomes measures Retention in care defined as one clinic visit or pharmacy refill in the prior 6 months; HIV-1 viral suppression defined as < 400 copies/ml. Results Overall, among 241 adolescents and young adults, retention was 89% (214/241) and viral suppression was 81% (196/241). Retention was higher among those attending adolescent clinic (95%) versus standard pediatric clinic (85%; OR 3.7; 95% confidence interval (CI) 1.2–11.1; p = 0.018). Multivariable logistic regression adjusted for age at ART initiation, gender, pre-ART CD4 count, months on ART, and tuberculosis history indicated higher odds of retention in adolescents and young adults attending adolescent compared to standard clinic (AOR = 8.5; 95% CI 2.3–32.4; p = 0.002). Viral suppression was higher among adolescents and young adults attending adolescent (91%) versus standard pediatric clinic (80%; OR 2.5; 95% CI 1.1–5.8; p = 0.028). A similar multivariable logistic regression model indicated higher odds of viral suppression in adolescents and young adults attending adolescent versus standard pediatric clinic (AOR = 3.8; 95% CI 1.5–9.7; p = 0.005). Conclusion Adolescents and young adults attending an adolescent-friendly clinic had higher retention in care and viral suppression compared to adolescents attending the standard pediatric clinic. Further studies are needed to prospectively assess the impact of adolescent-friendly services on these outcomes.
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Affiliation(s)
- Brian C. Zanoni
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Thobekile Sibaya
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
| | | | - Sara Lammert
- University of Minnesota, Minneapolis, Minnesota, United States of America
| | - Jessica E. Haberer
- Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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Georgette N, Siedner MJ, Petty CR, Zanoni BC, Carpenter S, Haberer JE. Impact of a clinical program using weekly Short Message Service (SMS) on antiretroviral therapy adherence support in South Africa: a retrospective cohort study. BMC Med Inform Decis Mak 2017; 17:18. [PMID: 28219372 PMCID: PMC5319177 DOI: 10.1186/s12911-017-0413-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In randomized controlled trials, short message service (SMS) programs have improved adherence to HIV antiretroviral therapy (ART). In response, the World Health Organization recommended use of SMS programs to support ART. However, there is limited data on real-world implementations of SMS programs. METHODS We conducted a retrospective cohort study of an SMS program to improve ART adherence in a government-run HIV clinic in rural South Africa. We analyzed data from all adult patients who 1) enrolled at the clinic before the observation period (July 2013 through June 2014), 2) had ≥1 ART prescriptions in the observation period, and 3) had data on phone number availability (N = 2255). Our main outcome measure was prescription coverage, defined as the presence of a valid ART prescription for each day observed. We fit generalized linear mixed models adjusted for pre-program prescription coverage, demographics, and ART duration, dosing, and regimen. RESULTS Exposure to the SMS program was independently associated with greater prescription coverage (AOR = 1.23, 95% CI 1.13-1.34, P < 0.001) compared with non-exposure, although the absolute increase in prescription coverage was small (4.7 days of ART prescription coverage per average patient per year). Among a subset of patients (n = 725) whose pre-program prescription coverage was <100%, the corresponding mean expected absolute increase in prescription coverage was 8.2 days per year. CONCLUSIONS Our primary finding was that an SMS reminder program implemented in routine clinical care was associated with a small increase in prescription coverage of uncertain clinical significance.
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Affiliation(s)
| | - Mark J Siedner
- Harvard Medical School, Boston, MA, USA.,Department of Medicine/Global Health, Massachusetts General Hospital, Boston, MA, USA.,Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Brian C Zanoni
- Harvard Medical School, Boston, MA, USA.,Department of Medicine/Global Health, Massachusetts General Hospital, Boston, MA, USA
| | | | - Jessica E Haberer
- Harvard Medical School, Boston, MA, USA.,Department of Medicine/Global Health, Massachusetts General Hospital, Boston, MA, USA
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Zanoni BC, Archary M, Buchan S, Katz IT, Haberer JE. Systematic review and meta-analysis of the adolescent HIV continuum of care in South Africa: the Cresting Wave. BMJ Glob Health 2016; 1:e000004. [PMID: 28588949 PMCID: PMC5321340 DOI: 10.1136/bmjgh-2015-000004] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 06/23/2016] [Accepted: 08/08/2016] [Indexed: 11/03/2022] Open
Abstract
CONTEXT South Africa has the most HIV infections of any country in the world, yet little is known about the adolescent continuum of care from HIV diagnosis through viral suppression. OBJECTIVE To determine the adolescent HIV continuum of care in South Africa. DATA SOURCES We searched PubMed, Google Scholar and online conference proceedings from International AIDS Society (IAS), International AIDS Conference (AIDS) and Conference on Retrovirology and Opportunistic Infections (CROI) from 1 January 2005 to 31 July 2015. DATA EXTRACTION We selected published literature containing South African cohorts and epidemiological data reporting primary data for youth (15-24 years of age) at any stage of the HIV continuum of care (ie, diagnosis, treatment, retention, viral suppression). For the meta-analysis we used six sources for retention in care and nine for viral suppression. RESULTS Among the estimated 867 283 HIV-infected youth from 15 to 24 years old in South Africa in 2013, 14% accessed antiretroviral therapy (ART). Of those on therapy, ∼83% were retained in care and 81% were virally suppressed. Overall, we estimate that 10% of HIV-infected youth in South Africa in 2013 were virally suppressed. LIMITATIONS This analysis relies on published data from large mostly urban South Africa cohorts limiting the generalisability to all adolescents. CONCLUSIONS Despite a large increase in ART programmes in South Africa that have relatively high retention rates and viral suppression rates among HIV-infected youth, only a small percentage are virally suppressed, largely due to low numbers of adolescents and young adults accessing ART.
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Affiliation(s)
- Brian C Zanoni
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Moherndran Archary
- University of KwaZulu-Natal Nelson Mandela School of Medicine, Durban, South Africa
- Department of Pediatrics, King Edward Hospital, Durban, South Africa
| | - Sarah Buchan
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid T Katz
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jessica E Haberer
- Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Despite enormous improvements in effectiveness of treatment for HIV infection, opportunistic infections continue to occur in those who have not yet been diagnosed with HIV and in those who are not receiving antiretroviral therapy. This review focuses on tuberculosis and cryptococcal infections, the most common opportunistic infections (OIs) in patients living with human immunodeficiency virus infection around the world, as well as on new developments in progressive multifocal leukoencephalopathy and pneumocystis pneumonia. In the sections on these conditions, updates on diagnosis, treatment, and complications, as well as information on when to start antiretroviral therapy is provided. The article concludes with a discussion of new data on 2 vaccine-preventable OIs, human papillomavirus and varicella-zoster virus.
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Affiliation(s)
- Brian C Zanoni
- Infectious Diseases Division, Massachusetts General Hospital, GRJ 504, 55 Fruit Street, Boston, MA 02114, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA
| | - Rajesh T Gandhi
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Infectious Diseases Division and Ragon Institute, Massachusetts General Hospital, GRJ 504, 55 Fruit Street, Boston, MA 02114, USA.
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Zanoni BC, Mayer KH. The adolescent and young adult HIV cascade of care in the United States: exaggerated health disparities. AIDS Patient Care STDS 2014; 28:128-35. [PMID: 24601734 DOI: 10.1089/apc.2013.0345] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Little is known about how adolescents and young adults contribute to the declines in the cascade of care from HIV-1 diagnosis to viral suppression. We reviewed published literature from the Unites States reporting primary data for youth (13-29 years of age) at each stage of the HIV cascade of care. Approximately 41% of HIV-infected youth in the United States are aware of their diagnosis, while only 62% of those diagnosed engage medical care within 12 months of diagnosis. Of the youth who initiate antiretroviral therapy, only 54% achieve viral suppression and a further 57% are not retained in care. We estimate less than 6% of HIV-infected youth in the United States remain virally suppressed. We explore the cascade of care from HIV diagnosis through viral suppression for HIV-infected adolescents and young adults in the United States to highlight areas for improvement in the poor engagement of the infected youth population.
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Affiliation(s)
- Brian C. Zanoni
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Charlestown, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Kenneth H. Mayer
- Harvard Medical School, Boston, Massachusetts
- Fenway Health, Boston, Massachusetts
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Abstract
BACKGROUND With improved access to pediatric antiretroviral therapy (ART) in resource-limited settings, more children could experience first-line ART treatment failure. METHODS We performed a retrospective cohort analysis using electronic medical records from HIV-infected children who initiated ART at McCord Hospital's Sinikithemba Clinic in KwaZulu-Natal, South Africa, from August 2003 to December 2010. We analyzed all records from children who began second-line ART due to first-line treatment failure. We used logistic regression to compare viral outcomes in Protease Inhibitor (PI)-based versus Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI)-based second-line ART, controlling for time on first-line ART, sex, and whether HIV genotyping guided the regimen change. RESULTS Of the 880 children who initiated ART during this time period, 80 (9.1%) switched to second-line ART due to therapeutic failure of first-line ART after a median of 95 weeks (IQR 65-147 weeks). Eight (10%) of the failures received NNRTI-based second-line ART, all of whom failed a PI-based first-line regimen. Seventy (87.5%) received PI-based second-line ART, all of whom failed a NNRTI-based first-line regimen. Two children (2.5%) received non-standard dual therapy as second-line ART. Six months after switching ART regimens, the viral suppression rate was significantly higher in the PI group (82%) than in the NNRTI group (29%; p=0.003). Forty-one children (51%) were tested for genotypic resistance prior to switching to second-line ART. There was no significant difference in six month viral suppression (p=0.38) between children with and without genotype testing. CONCLUSION NNRTI-based second-line ART carries a high risk of virologic failure compared to PI-based second-line ART.
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Affiliation(s)
- Brian C. Zanoni
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Charlestown, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Henry Sunpath
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
- Infectious Diseases Unit, Nelson Mandela School of Medicine, Durban, South Africa
| | - Margaret E. Feeney
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Charlestown, Massachusetts, United States of America
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
- Division of Experimental Medicine, University of California San Francisco, San Francisco, California, United States of America
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Zanoni BC, Phungula T, Zanoni HM, France H, Cook EF, Feeney ME. Predictors of poor CD4 and weight recovery in HIV-infected children initiating ART in South Africa. PLoS One 2012; 7:e33611. [PMID: 22438965 PMCID: PMC3306429 DOI: 10.1371/journal.pone.0033611] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 02/13/2012] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To identify baseline demographic and clinical risk factors associated with poor CD4 and weight response after initiation of antiretroviral therapy (ART) in a cohort of human immunodeficiency virus (HIV)-infected children in KwaZulu-Natal, South Africa. METHODS We performed a retrospective cohort study of 674 children initiating antiretroviral therapy at McCord and St. Mary's hospitals in KwaZulu-Natal, South Africa, from August 2003 to December 2008. We extracted data from paper charts and electronic medical records to assess risk factors associated with CD4 and weight response using logistic regression. RESULTS From the initial cohort of 901 children <10 years old initiating ART between August 2003 and December 2008, we analyzed 674 children with complete baseline data. Viral suppression rates (<400 copies/ml) were 84% after six months of therapy and 88% after 12 months of therapy. Seventy-three percent of children achieved CD4 recovery after six months and 89% after 12 months. Weight-for-age Z-score (WAZ) improvements were seen in 58% of children after six months of ART and 64% after 12 months. After six months of ART, lower baseline hemoglobin (p = 0.037), presence of chronic diarrhea (p = 0.007), and virologic failure (p = 0.046) were all associated with poor CD4 recovery by multivariate logistic regression. After 12 months of ART, poor CD4 recovery was associated with higher baseline CD4% (p = 0.005), chronic diarrhea (p = 0.02), and virologic failure (p<0.001). Age less than 3 years at ART initiation (p = 0.0003), higher baseline CD4% (p<0.001), and higher baseline WAZ (p<0.001) were all associated with poor WAZ improvements after 6 months by multivariate logistic regression. CONCLUSION The presence of chronic diarrhea at baseline, independent of nutritional status and viral response, predicts poor CD4 recovery. Age at initiation of ART is an important factor in early WAZ response to ART, while viral suppression strongly predicts CD4 recovery but not WAZ improvement.
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Affiliation(s)
- Brian C. Zanoni
- The Ragon Institute of MGH, MIT and Harvard, Charlestown, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Thuli Phungula
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Holly M. Zanoni
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Holly France
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - E. Francis Cook
- Harvard School of Public Health, Boston, Massachusetts, United States of America
| | - Margaret E. Feeney
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
- Division of Experimental Medicine, University of California San Francisco, San Francisco, California, United States of America
- * E-mail:
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Ruel TD, Zanoni BC, Ssewanyana I, Cao H, Havlir DV, Kamya M, Achan J, Charlebois ED, Feeney ME. Sex differences in HIV RNA level and CD4 cell percentage during childhood. Clin Infect Dis 2011; 53:592-9. [PMID: 21840929 DOI: 10.1093/cid/cir484] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND HIV-infected women have lower HIV RNA levels and higher CD4-cell counts than do men. This observation has been attributed to the immunomodulatory effects of sex steroid hormones, such as estrogen and progesterone. Limited data exist regarding potential sex differences in HIV RNA level and CD4 parameters among prepubertal children with untreated HIV infection. METHODS We examined the relationship of sex to HIV RNA level and CD4 parameters among 670 perinatally HIV-infected, antiretroviral therapy-naive African children aged <18 years (median age, 4.8 years) using multivariate linear regression. In a subset of 188 children, we used longitudinal data to compare changes in HIV RNA levels and CD4 percentage over time. Levels of CD4 and CD8 T-cell activation (CD38+HLA-DR+) were also compared between boys and girls. RESULTS Female children had lower HIV RNA levels (P = .0004) and higher CD4 percentages (P < .0001), compared to male children. Multivariate linear regression demonstrated an independent association of sex with both HIV RNA level and CD4 percentages after controlling for other covariates. Multilevel mixed-effects linear regression analysis of longitudinal HIV RNA level and CD4 parameter data showed that sex differences persisted across all observed ages. Levels of T-cell activation did not differ between the sexes. CONCLUSIONS Significant sex differences in HIV RNA levels and CD4 parameters are present in HIV-infected children before the onset of puberty. These data suggest that intrinsic genetic differences between male and female individuals, unrelated to sex steroid hormone levels, influence HIV RNA level and CD4 parameters in HIV-infected individuals.
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Affiliation(s)
- Theodore D Ruel
- Department of Pediatrics, University of California, San Francisco, California, USA
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Zanoni BC, Phungula T, Zanoni HM, France H, Feeney ME. Risk factors associated with increased mortality among HIV infected children initiating antiretroviral therapy (ART) in South Africa. PLoS One 2011; 6:e22706. [PMID: 21829487 PMCID: PMC3146475 DOI: 10.1371/journal.pone.0022706] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Accepted: 07/05/2011] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To identify demographic and clinical risk factors associated with mortality after initiation of antiretroviral therapy (ART) in a cohort of human immunodeficiency (HIV) infected children in KwaZulu-Natal, South Africa. METHODS We performed a retrospective cohort study of 537 children initiating antiretroviral therapy at McCord Hospital in KwaZulu-Natal, South Africa. Data were extracted from electronic medical records and risk factors associated with mortality were assessed using Cox regression analysis. RESULTS Overall there were 47 deaths from the cohort of 537 children initiating ART with over 991 child-years of follow-up (median 22 months on ART), yielding a mortality rate of 4.7 deaths per 100 child years on ART. Univariate analysis indicated that mortality was significantly associated with lower weight-for-age Z-score (p<0.0001), chronic diarrhea (p = 0.0002), lower hemoglobin (p = 0.002), age <3 years (p = 0.003), and CD4% <10% (p = 0.005). The final multivariable Cox proportional hazards mortality model found age less than 3 years (p = 0.004), CD4 <10% (p = 0.01), chronic diarrhea (p = 0.03), weight-for-age Z-score (<0.0001) and female gender as a covariate varying with time (p = 0.03) all significantly associated with mortality. CONCLUSION In addition to recognized risk factors such as young age and advanced immunosuppression, we found female gender to be significantly associated with mortality in this pediatric ART cohort. Future studies are needed to determine whether intrinsic biologic differences or socio-cultural factors place female children with HIV at increased risk of death following initiation of ART.
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Affiliation(s)
- Brian C. Zanoni
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Charlestown, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Thuli Phungula
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Holly M. Zanoni
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Holly France
- Sinikithemba Clinic and Philani Program, McCord Hospital, Durban, South Africa
| | - Margaret E. Feeney
- The Ragon Institute of Massachusetts General Hospital, Massachusetts Institute of Technology, and Harvard, Charlestown, Massachusetts, United States of America
- Division of Experimental Medicine, University of California San Francisco, San Francisco, California, United States of America
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Snyder J, Zanoni BC. Caring comportment and the hospitalist model. AMA J Ethics 2006; 8:114-117. [PMID: 23228543 DOI: 10.1001/virtualmentor.2006.8.2.oped2-0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Affiliation(s)
- Jeremy Snyder
- Graduate student completing a doctorate in philosophy at Georgetown University
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Kordik CP, Luo C, Zanoni BC, Dax SL, McNally JJ, Lovenberg TW, Wilson SJ, Reitz AB. Aminopyrazoles with high affinity for the human neuropeptide Y5 receptor. Bioorg Med Chem Lett 2001; 11:2283-6. [PMID: 11527715 DOI: 10.1016/s0960-894x(01)00448-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
1,3-Disubstituted-5-aminopyrazoles were prepared based on a lead compound found through high-throughput screening of our corporate compound library in an assay measuring affinity for the human neuropeptide Y5 receptor. The target compounds were prepared by cyclization of alpha-cyanoketones with appropriate hydrazines, followed by reduction and coupling to various sulfonamido-carboxylic acids. Several of these arylpyrazoles (e.g., 19 and 45) displayed high affinity for the human NPY Y5 receptor (<20nM IC(50)s).
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Affiliation(s)
- C P Kordik
- Drug Discovery Division, The R. W. Johnson Pharmaceutical Research Institute, Welsh and McKean Roads, Spring House, PA 19477, USA.
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Kordik CP, Luo C, Zanoni BC, Lovenberg TW, Wilson SJ, Vaidya AH, Crooke JJ, Rosenthal DI, Reitz AB. Pyrazolecarboxamide human neuropeptide Y5 receptor ligands with in vivo antifeedant activity. Bioorg Med Chem Lett 2001; 11:2287-90. [PMID: 11527716 DOI: 10.1016/s0960-894x(01)00449-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
1-Aryl-3-carboxamido-5-alkylpyrazoles were prepared based on a hit found in high-throughput screening of our corporate compound library in an assay measuring affinity for the human neuropeptide Y5 receptor. 1-(3-Trifluoromethylphenyl)-3-[N-(5-quinolinyl)carboxamido]-5-methylpyrazole (31) bound to the human neuropeptide Y5 receptor with a 80 nM IC(50 )and was shown to inhibit cumulative food consumption 43.2% 2-6 h after ip dosing in a fasting-induced feeding model in rats.
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Affiliation(s)
- C P Kordik
- Drug Discovery Division, The R. W. Johnson Pharmaceutical Research Institute, Welsh and McKean Roads, Spring House, PA 19477, USA.
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