Equity of child and adolescent treatment, continuity of care and mortality, according to age and gender among enrollees in a large HIV programme in Tanzania

Abstract Introduction: Global scale up of anti‐retroviral therapy (ART) has led to expansion of HIV treatment and prevention across sub‐Saharan Africa. However, age and gender‐specific disparities persist leading to failures in fulfillment of Sustainability Development Goals, including SDG3 (achieving healthy lives and wellbeing for all, at all ages) and SDG5 (gender equality). We assessed ART initiation and adherence, loss to follow‐up, all‐cause death and early death, according to SDG3 and SDG5 indicators among a cohort of HIV‐infected children and adolescents enrolled in care in Dar‐es‐Salaam, Tanzania Methods: SDG3 indicators included young (<5 years) and older paediatric children (5 to <10 years), early adolescent (10 to <15 years) and late adolescent (15 to <20 years) age group divisions and the SDG5 indicator was gender. Associations of age group and gender with ART initiation, loss to follow‐up and all‐cause death, were analysed using Cox proportional hazards regression and with adherence, using generalized estimating equations (GEE) with the Poisson distribution. Associations of age group and gender with early death were analysed, using log‐Poisson regression with empirical variance. Results: A total of 18,315 enrollees with at least one clinic visit were included in this cohort study. Of these 7238 (40%) were young paediatric , 4169 (23%) older paediatric, 2922 (16%) early adolescent and 3986 (22%) late adolescent patients at enrolment. Just over half of paediatric and early adolescents and around four fifths of the late adolescents were female. Young paediatric patients were at greater risk of early death, being almost twice as likely to die within 90 days. Males were at greater risk of early death once initiated on ART (HR 1.35, 95% CI 1.09, 1.66)), while females in late adolescence were at greatest risk of late death (HR 2.44 [1.60, 3.74] <0.01). Late adolescents demonstrated greater non‐engagement in care (RR 1.21 (95% CI 1.16, 1.26)). Among both males and females, early paediatric and late adolescent groups experienced significantly greater loss to follow‐up. Conclusion: These findings highlight equity concerns critical to the fulfillment of SDG3 and SDG5 within services for children and adolescents living with HIV in sub‐Saharan Africa. Young paediatric and late adolescent age groups were at increased risk of late diagnosis, early death, delayed treatment initiation and loss of continuity of care. Males were more likely to die earlier. Special attention to SDG3 and SDG5 disparities for children and adolescents living with HIV will be critical for fulfillment of the 2030 SDG agenda

Cost analysis of large-scale implementation of the ‘Helping Babies Breathe’ newborn resuscitation-training program in Tanzania

Background: Helping Babies Breathe (HBB) has become the gold standard globally for training birth-attendants in neonatal resuscitation in low-resource settings in efforts to reduce early newborn asphyxia and mortality. The purpose of this study was to do a first-ever activity-based cost-analysis of at-scale HBB program implementation and initial follow-up in a large region of Tanzania and evaluate costs of national scale-up as one component of a multi-method external evaluation of the implementation of HBB at scale in Tanzania. Methods: We used activity-based costing to examine budget expense data during the two-month implementation and follow-up of HBB in one of the target regions. Activity-cost centers included administrative, initial training (including resuscitation equipment), and follow-up training expenses. Sensitivity analysis was utilized to project cost scenarios incurred to achieve countrywide expansion of the program across all mainland regions of Tanzania and to model costs of program maintenance over one and five years following initiation. Results: Total costs for the Mbeya Region were $202,240, with the highest proportion due to initial training and equipment (45.2$4,000,000 (around $600 per facility). Following sensitivity analyses, the estimated total for all Tanzania initial rollout lies between$2,934,793 to $4,309,595. In order to maintain the program nationally under the current model, it is estimated it would cost$2,019,115 for a further one year and $5,640,794 for a further five years of ongoing program support. Conclusion: HBB implementation is a relatively low-cost intervention with potential for high impact on perinatal mortality in resource-poor settings. It is shown here that nationwide expansion of this program across the range of health provision levels and regions of Tanzania would be feasible. This study provides policymakers and investors with the relevant cost-estimation for national rollout of this potentially neonatal life-saving intervention

The Neurodevelopment and Mental Health of Children Affected by HIV in Sub-Saharan Africa

This dissertation assesses neurodevelopment in children affected by HIV in Botswana, by examining associations between a range of factors and neurodevelopmental outcomes at 24 months of age and adjusting for potential confounders through linear regression. We followed children from birth to approximately 24 months to assess their neurodevelopment with an adapted version of Bayley Scales of Infant Development third edition (BSIDIII: cognitive, gross motor, fine motor, expressive and receptive language domains) and with the Development Milestones Checklist (DMC: locomotor, fine motor, language and personal-social domains), a parent-completed questionnaire. Chapter I compares neurodevelopment between HIV-exposed uninfected (HEU) children whose mothers took antenatal 3-drug combination antiretroviral therapy (ART) vs. zidovudine (ZDV) within a prospective study, nested within two cohorts of HIV-infected mothers and their children in Botswana (one observational, one interventional). We observed that neurodevelopmental outcomes at 24 months of age were generally at least as good among HEU children exposed in utero to ART when compared to those exposed in utero to ZDV. Chapter II compares neurodevelopment between HEU vs. HIV-unexposed uninfected (HUU) children in Botswana, within a prospective observational study. We observed that neurodevelopmental outcomes at 24 months among HEU children were generally as good as those among unexposed children. Results from Chapter I and II provide reassurance, easing concerns that HIV or ARV-exposure may detrimentally affect neurodevelopment in young children. Chapter III examines the potential of a family-based intervention for use in reducing harmful alcohol use and intimate partner violence, to protect and promote child mental health, within families affected by HIV in Rwanda. Quantitative data from a randomized controlled trial (RCT) were analyzed to demonstrate significant reductions in alcohol-use and intimate partner violence within HIV-affected families receiving the intervention, when compared to control families. Quantitative and qualitative data from the RCT, were integrated using a mixed-method approach, and support the potential of family-based interventions to reduce adverse caregiver behaviors as a major mechanism for improving child well-being, for families affected by HIV in Sub-Saharan Africa

HIV Status Disclosure through Family-Based Intervention Supports Parenting and Child Mental Health in Rwanda

Introduction: Few evidence-based interventions exist to support parenting and child mental health during the process of caregiver HIV status disclosure in sub-Saharan Africa. A secondary analysis of a randomized-controlled trial was conducted to examine the role of family-based intervention versus usual social work care (care as usual) in supporting HIV status disclosure within families in Rwanda. Method: Approximately 40 households were randomized to family-based intervention and 40 households to care as usual. Parenting, family unity, and child mental health during the process of disclosure were studied using quantitative and qualitative research methods. Results: Many of the families had at least one caregiver who had not disclosed their HIV status at baseline. Immediately post-intervention, children reported lower parenting and family unity scores compared with those in the usual-care group. These changes resolved at 3-month follow-up. Qualitative reports from clinical counselor intervention sessions described supported parenting during disclosure. Overall findings suggest adjustments in parenting, family unity, and trust surrounding the disclosure process. Conclusion: Family-based intervention may support parenting and promote child mental health during adjustment to caregiver HIV status disclosure. Further investigation is required to examine the role of family-based intervention in supporting parenting and promoting child mental health in HIV status disclosure

Exploring the potential of a family-based prevention intervention to reduce alcohol use and violence within HIV-affected families in Rwanda

HIV-affected families report higher rates of harmful alcohol use, intimate partner violence (IPV) and family conflict, which can have detrimental effects on children. Few evidence-based interventions exist to address these complex issues in Sub-Saharan Africa. This mixed methods study explores the potential of a family-based intervention to reduce IPV, family conflict and problems related to alcohol use to promote child mental health and family functioning within HIV-affected families in post-genocide Rwanda. A family home-visiting, evidence-based intervention designed to identify and enhance resilience and communication in families to promote mental health in children was adapted and developed for use in this context for families affected by caregiver HIV in Rwanda. The intervention was adapted and developed through a series of pilot study phases prior to being tested in open and randomized controlled trials (RCTs) in Rwanda for families affected by caregiver HIV. Quantitative and qualitative data from the RCT are explored here using a mixed methods approach to integrate findings. Reductions in alcohol use and IPV among caregivers are supported by qualitative reports of improved family functioning, lower levels of violence and problem drinking as well as improved child mental health, among the intervention group. This mixed methods analysis supports the potential of family-based interventions to reduce adverse caregiver behaviors as a major mechanism for improving child well-being. Further studies to examine these mechanisms in well-powered trials are needed to extend the evidence-base on the promise of family-based intervention for use in low- and middle-income countries

Exploring the potential of a family-based prevention intervention to reduce alcohol use and violence within HIV-affected families in Rwanda.

HIV-affected families report higher rates of harmful alcohol use, intimate partner violence (IPV) and family conflict, which can have detrimental effects on children. Few evidence-based interventions exist to address these complex issues in Sub-Saharan Africa. This mixed methods study explores the potential of a family-based intervention to reduce IPV, family conflict and problems related to alcohol use to promote child mental health and family functioning within HIV-affected families in post-genocide Rwanda. A family home-visiting, evidence-based intervention designed to identify and enhance resilience and communication in families to promote mental health in children was adapted and developed for use in this context for families affected by caregiver HIV in Rwanda. The intervention was adapted and developed through a series of pilot study phases prior to being tested in open and randomized controlled trials (RCTs) in Rwanda for families affected by caregiver HIV. Quantitative and qualitative data from the RCT are explored here using a mixed methods approach to integrate findings. Reductions in alcohol use and IPV among caregivers are supported by qualitative reports of improved family functioning, lower levels of violence and problem drinking as well as improved child mental health, among the intervention group. This mixed methods analysis supports the potential of family-based interventions to reduce adverse caregiver behaviors as a major mechanism for improving child well-being. Further studies to examine these mechanisms in well-powered trials are needed to extend the evidence-base on the promise of family-based intervention for use in low- and middle-income countries