Precarious hope and reframing risk behavior from the ground up: insight from ethnographic research with Rwandan urban refugees in Yaoundé, Cameroon.

BackgroundTheoretical and methodological research on risk-taking practices often frames risk as an individual choice. While risk does occur at individual level, it is determined by aspirations which are connected to others and society. For many displaced women globally, these aspirations are often linked to the well-being of their children and other household members. This article explores the links between aspirations for the future, gendered household dynamics, and health risk-taking behavior among the Rwandan urban refugee community.MethodsThis analysis drew from participant observation, focus group discussions, and in-depth interviews with 49 male and 42 female household members from 36 Rwandan refugee households in Yaoundé, Cameroon. The fieldwork was conducted over 12 months between May-August 2016, May-August 2017, and February-August 2018.ResultsWe observed that while there was considerable convergence among household members in aspirations, there was considerable difference in risk-taking practices engaged to achieve them with women often assuming the greatest risks. These gendered realities of risk were not only related to structural concerns including access to different forms of capital, but also to socio-cultural gendered expectations of women, how risks were defined and justified, and household dynamics that drove the gendered reality of observed risk-behavior.ConclusionsHumanitarian programs and policies are distinctly finite in nature; focused on the short-term needs of persons affected by conflict. However, many humanitarian situations in the world are protracted. In the midst of these challenges, themes of future-orientation, possibilities, and shared aspirations for a better future emerge. These aspirations and the practices, including risk-taking practices that stem from them are central to understand if we are to ensure a just peace and stability in displaced communities throughout the developing world. Our analysis highlights the need to examine sociocultural dimensions related to hopes for the future, gender, and household dynamics as a way to understand risk behavior. We propose this can be done through a framework of precarious hope which we put forward in this paper, in which hope, agency, sociocultural and political economic contexts situate risk as a gendered practice of hope amidst constraint

Optimization of pediatric antiretroviral therapy in sub-Saharan Africa : timing of initiation in HIV/TB co-infected children and using gains in weight, height, or CD4 count to monitor the response

Backgroung: Antiretroviral therapy (ART) has revolutionized the treatment of HIV, but substantial drug interactions between anti-TB and ART and the lack of health care infrastructures complicate the management of HIV/TB co-infected children in resource poor countries. More than 50% of TB infected children in some high burden countries in sub-Saharan Africa are also infected with HIV, but the optimal timing of ART in those children is unknown. In addition, though the drug-interactions and the high pill burden to treat HIV and TB require strict monitoring, regular measurements of viral load that is routine for ART monitoring in developed countries is not always possible in sub-Saharan Africa. This study had two aims. 1) Construct reference charts for gains in weight, height, absolute CD4 count, and CD4% in the first 6 months of ART, and to test the value of the 3rd, 10th, 25th, 33rd, and 50th percentiles as predictors of subsequent death, virological suppression, or treatment failure. 2) Determine the effect of delaying ART for at least 15, 30, or 60 days in HIV/TB co-infected children on virological suppression and survival. Methods: We used information from an observational clinical cohort of HIV-infected children who sought care at an outpatient clinic at Chris Hani Baragwanath Hospital in Soweto, South Africa. To construct the reference charts, we assumed a Box Cox power exponential distribution for the 6 month gains in weight, height, CD4 count and CD4% and used the generalized additive model for location, scale, and shape to estimate the parameters of each of the four distributions. Hazard ratios for the association of the selected centiles with the three outcomes were estimated using Cox proportional hazard model. For aim 2, though per guidelines all HIV-infected children with TB were eligible for ART, the decision whether to initiate or delay ART for a given child was made at each visit and sicker children were initiated earlier. Moreover, some children for whom ART was delayed could die before it was possible to classify them for exposure. To control for the time-dependent confounding by indication and the lead time on survival, mortality hazard ratios were estimated using the inverse-probability-of-treatment-weighting of marginal structural modelling. Adjusted hazard ratios for virological suppression were estimated using multivariate Cox proportional modelling. Results: Overall, information from 1394 and from 573 children was used for aim 1 and aim 2 respectively. Children whose weight, absolute CD4, or CD4% gain were below the 33rd percentile for age or gender had poorer ART outcomes with a three to four-fold higher hazard of death, about 0.75 -fold lower hazard of virological suppression and about two-fold higher hazard of treatment failure. Delaying ART tended to be associated with increased mortality: adjusted hazard ratios (aHR) for 15, 30, and 60 days delay were: 0.90 (95%CI: 0.30, 2.75), 1.05 (95%CI: 0.29, 3.75), 2.18 (95%CI: 0.64, 7.48) respectively. Delaying ART appear to be potentially detrimental for the hazard of viral suppression: aHR: 0.98 (95%CI: 0.76, 1.26), 0.95, (95%CI: 0.73, 1.23), 0.84 (95%CI: 0.61, 1.15) for 15, 30, and 60 days delay respectively. Conclusion: Six-month weight gain and CD4 cell gain (count and CD4%) below the 33rd percentile were equally strong predictors of poor ART outcomes suggesting that, pending construction of more generalizable charts, weight gain can be used in children on ART to discriminate those who are failing the treatment from those who are responding. Since delaying ART beyond 30 days appears to negatively affect both survival and viral response, the recommendation should be reevaluated and necessary delays should not exceed 30 days

Association Between Pregnancy at Enrollment into HIV Care and Loss to Care Among Women in the Democratic Republic of Congo, 2006-2013

BACKGROUND: Loss to care is high among asymptomatic HIV-infected women initiated on antiretroviral therapy (ART) during pregnancy or in the postpartum period. However, whether pregnancy itself plays a role in the high loss to care rate is uncertain. We compared loss to care over seven years between pregnant and non-pregnant women at enrollment into HIV care in the Democratic Republic of Congo (DRC). METHODS: We conducted a retrospective analysis of all ART-naive women aged 15-45 initiating HIV care at two large clinics in Kinshasa, DRC, from 2007-2013. Pregnancy status was recorded at care enrollment. Patients were classified as having no follow-up if they did not return to care after the initial enrollment visit. Among those with at least one follow-up visit after enrollment, we classified patients as lost to care if more than 365 days had passed since their last clinic visit. We used logistic regression to model the association between pregnancy status and no follow-up, and Cox proportional hazards regression to model the association between pregnancy status and time to loss to care. RESULTS: Of 2175 women included in the analysis, 1497 (68.8%) were pregnant at enrollment. Compared to non-pregnant women, pregnant women were less likely to be over 35 years of age (19.1% vs. 31.9%,

Growth and CD4 patterns of adolescents living with perinatally acquired HIV worldwide, a CIPHER cohort collaboration analysis

HIV; Adolescent; Perinatally acquiredVIH; Adolescent; Adquirit perinatalmentVIH; Adolescente; Adquirida perinatalmenteIntroduction Adolescents living with HIV are subject to multiple co-morbidities, including growth retardation and immunodeficiency. We describe growth and CD4 evolution during adolescence using data from the Collaborative Initiative for Paediatric HIV Education and Research (CIPHER) global project. Methods Data were collected between 1994 and 2015 from 11 CIPHER networks worldwide. Adolescents with perinatally acquired HIV infection (APH) who initiated antiretroviral therapy (ART) before age 10 years, with at least one height or CD4 count measurement while aged 10–17 years, were included. Growth was measured using height-for-age Z-scores (HAZ, stunting if <-2 SD, WHO growth charts). Linear mixed-effects models were used to study the evolution of each outcome between ages 10 and 17. For growth, sex-specific models with fractional polynomials were used to model non-linear relationships for age at ART initiation, HAZ at age 10 and time, defined as current age from 10 to 17 years of age. Results A total of 20,939 and 19,557 APH were included for the growth and CD4 analyses, respectively. Half were females, two-thirds lived in East and Southern Africa, and median age at ART initiation ranged from 7 years in sub-Saharan African regions. At age 10, stunting ranged from 6% in North America and Europe to 39% in the Asia-Pacific; 19% overall had CD4 counts <500 cells/mm3. Across adolescence, higher HAZ was observed in females and among those in high-income countries. APH with stunting at age 10 and those with late ART initiation (after age 5) had the largest HAZ gains during adolescence, but these gains were insufficient to catch-up with non-stunted, early ART-treated adolescents. From age 10 to 16 years, mean CD4 counts declined from 768 to 607 cells/mm3. This decline was observed across all regions, in males and females. Conclusions Growth patterns during adolescence differed substantially by sex and region, while CD4 patterns were similar, with an observed CD4 decline that needs further investigation. Early diagnosis and timely initiation of treatment in early childhood to prevent growth retardation and immunodeficiency are critical to improving APH growth and CD4 outcomes by the time they reach adulthood.This work was supported by the International AIDS Society – Collaborative Initiative for Paediatric HIV Education & Research (IAS-CIPHER, http://www.iasociety.org/CIPHER), which is made possible through funding from CIPHER Founding Sponsor ViiV Healthcare (https://www.viivhealthcare.com) and Janssen (http://www.janssen.com)

CD4+ gain percentile curves for monitoring response to antiretroviral therapy in HIV-infected adults

We constructed CD4 count gain percentile distributions standardized by baseline CD4 count and assessed the association between poor CD4 count gain and subsequent death and virological failure on antiretroviral treatment (ART)

Time to First-Line ART Failure and Time to Second-Line ART Switch in the IeDEA Pediatric Cohort

BACKGROUND: Globally, 49% of the estimated 1.8 million children living with HIV are accessing antiretroviral therapy (ART). There are limited data concerning long-term durability of first-line ART regimens and time to transition to second-line. METHODS: Children initiating their first ART regimen between 2 and 14 years of age and enrolled in one of 208 sites in 30 Asia-Pacific and African countries participating in the Pediatric International Epidemiology Databases to Evaluate AIDS consortium were included in this analysis. Outcomes of interest were: first-line ART failure (clinical, immunologic, or virologic), change to second-line, and attrition (death or loss to program ). Cumulative incidence was computed for first-line failure and second-line initiation, with attrition as a competing event. RESULTS: In 27,031 children, median age at ART initiation was 6.7 years. Median baseline CD4% for children ≤5 years of age was 13.2% and CD4 count for those >5 years was 258 cells per microliter. Almost all (94.4%) initiated a nonnucleoside reverse transcriptase inhibitor; 5.3% a protease inhibitor, and 0.3% a triple nucleoside reverse transcriptase inhibitor-based regimen. At 1 year, 7.7% had failed and 14.4% had experienced attrition; by 5 years, the cumulative incidence was 25.9% and 29.4%, respectively. At 1 year after ART failure, 13.7% had transitioned to second-line and 11.2% had experienced attrition; by 5 years, the cumulative incidence was 31.6% and 25.9%, respectively. CONCLUSIONS: High rates of first-line failure and attrition were identified in children within 5 years after ART initiation. Of children meeting failure criteria, only one-third were transitioned to second-line ART within 5 years

Six-month gain in weight, height, and CD4 predict subsequent antiretroviral treatment responses in HIV-infected South African children

Construct percentile curves for 6-month gain in weight, height, CD4 cell count, and CD4 percentage (CD4%) in children initiating ART, and to assess the association between lower percentiles and subsequent ART responses. Cohort of 1394 HIV-infected children initiating ART between April 2004 and March 2008, Johannesburg, South Africa The generalized additive model for location, scale, and shape was used to construct percentile curves for 6-month gain in weight, height, CD4 cell count, and CD4%. Cox proportional models were used to assess the association between lower percentiles of each distribution and death, virological suppression, and treatment failure between 6 to 36 months post-ART initiation. Lower percentiles for gain in weight, CD4, and CD4% count after 6 months of ART, but not height, were associated with poor subsequent treatment outcomes independent of baseline characteristics, with increasing strength of association as percentiles decreased. Age-specific 6-month post-ART weight gain in our cohort was substantially higher compared with 6-month weight gain in non-HIV-infected American children of the Fels Institute cohort and the attained weight-for-age at 6 months post-ART plotted on WHO weight-for-age growth charts were not associated with subsequent treatment outcomes. Gain in CD4% in the first 6 months of ART was the best predictor of poor subsequent ART outcomes. In areas with limited access to CD4%, weight gain post-ART using our newly developed reference distributions for HIV-infected children on ART is a good alternative to CD4%, and clearly superior to the commonly used 'Road-to-Health' weight-for-age charts

Antiretroviral Therapy Responses Among Children Attending a Large Public Clinic in Soweto, South Africa

Antiretroviral therapy access with successful outcomes for children is expanding in resource limited countries. The aim of this study was to determine treatment responses of children in a routine setting where first line therapy with lopinavir/ritonavir is routinely included for young children