<p><strong>BACKGROUND: </strong>Pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection but is not yet widely available in resource-limited settings such as the Dominican Republic. We aimed to ascertain PrEP acceptability among people living with HIV in the Dominican Republic who are part of HIV serodiscordant partnerships and understand relationships between PrEP acceptability, HIV stigma, and intimate partner violence. A cross-sectional survey of people in care for HIV infection included acceptability-related questions and assessments of HIV stigma and intimate partner violence. We also explored the expected impact of PrEP on HIV disclosure rates and fertility intentions. Of the 100 participants, 74% had been in their current partnership for >1 year; 38% had not disclosed to their partner; 29% reported condomless sex, and 23% reported sex with multiple partners. PrEP was highly acceptable with 84% of participants saying they were "very likely" to offer PrEP to their partner if available and 21% stating it would allow them to have more children. Of those who had not disclosed to their partner, 71% stated PrEP would help them do so. No relationship was found between PrEP acceptability, HIV stigma, and intimate partner violence. However, higher than expected rates of PrEP acceptability limited the power of these analyses. Pre-exposure prophylaxis was considered to be highly acceptable among people living with HIV in the Dominican Republic who are part of serodiscordant partnerships.</p>
<p><strong>BACKGROUND: </strong>When planning interventions for adolescents, adult interventions should not be used 'as is' in youth settings. Stakeholder engagement can help understand the overall adolescent mental health ecosystem and adapt existing evidence-based interventions for the youth.</p>
<p><strong>OBJECTIVE: </strong>To understand the overall mental health needs of adolescents in Botswana and the necessary adaptations required for an adolescent lay counselor based intervention in the country.</p>
<p><strong>METHODS: </strong>We used the theory of change model and the nominal group technique in five stakeholder meetings. Meetings were held to discuss the mental health needs of youth in Botswana and identify priorities for a lay counsellor based intervention modelled after the Friendship Bench intervention, an existing mental health intervention for adults.</p>
<p><strong>RESULTS: </strong>The root causes of mental health problems among Botswana's youth identified by stakeholders included limited mental health knowledge among the youth and the community, family problems, poor communication, low self-esteem, the rapid growth of technology, and biological/genetic predisposition. Structurally barriers included: mental illness-related stigma, lack of psychosocial support, incomplete follow up for health services, cultural beliefs about mental illness, and fragmented mental health services. The stakeholders envisage a program that could empower adolescents and youth counselors to address mental health concerns for a healthier community. The group identified and prioritized several key elements of an effective lay counselor intervention.</p>
<p><strong>CONCLUSIONS: </strong>A diverse group of community stakeholders can illustrate critical mental health needs and elements that countries could use to adapt and contextualize a lay counsellor based mental health intervention for new populations such as the youth.</p>
<p>Despite access to nationally supplied antiretroviral treatment, viral load suppression rates remain suboptimal in the Dominican Republic. Counseling and support services are available but mainly targeted to those identified as having the most need. At Clínica de Familia La Romana (CFLR) in La Romana, all patients undergo a structured baseline interview including exploration of expected barriers to care. We conducted a retrospective cohort study of a random sample of patients at CFLR with treatment initiation between 1 January 2015 and 1 December 2017 to determine if self-identified barriers to HIV care predict viral load suppression. Viral load suppression occurred in 63% of the 203 patients evaluated. Lack of food ( = 19) was significantly associated with lack of viral suppression (OR 3.0, 95% CI 1.14-7.87). Nondisclosure of HIV status ( = 24) showed evidence for a protective effect (OR 0.33; 95% CI 0.11-1.0). Further steps should be taken to address food insecurity as well as to understand associated barriers to care among individuals with food insecurity.</p>
<p><strong>Background.</strong> Parents' beliefs about and engagement in reading aloud to young children and other positive parenting practices have been associated with early childhood development (ECD) and later achievement. <strong>Aim.</strong> This exploratory study sought to assess parental attitudes and self-reported practices regarding ECD in a rural, low-income community in the Dominican Republic with many risk factors for ECD delays, including high rates of poverty, iron-deficiency anemia, and malnutrition. <strong>Methods.</strong> We used the Parent Reading Belief Inventory and open-ended questions to evaluate parental beliefs regarding reading, self-efficacy in promoting child development, current positive parenting practices, and parents' concerns about the development of their 0- to 5-year-old children in Consuelo, Dominican Republic. We explored associations between demographic factors and strength of positive parenting beliefs and practices. <strong>Results.</strong> Overall participants had positive attitudes toward reading and their own importance in promoting their children's development. Participants with at least some high school education had significantly higher Parent Reading Belief Inventory scores ( = .03) than those with less formal education. Participants reported frequently singing, talking, and playing with their children, but less frequently reading with them. Few participants had access to reading materials for young children. Parental interest in programs to support ECD was high. Parents raised concerns about their children's behavior, personal and educational attainment, and early literacy. <strong>Conclusion.</strong> Children whose parents have less formal education may benefit most from interventions to promote beliefs and practices likely to improve ECD. In this community, there is high interest in learning more about ECD.</p>
<p>Psychological reactance is an aversive response to perceived threats against personal agency. For adolescents receiving HIV treatment in Botswana, we utilized a two-question, medication-specific reactance tool to assess whether: (1) verbal reminders to take medicines made adolescents want to avoid taking them, and, (2) whether adolescents felt anger when reminded to take medicines. Reactant adolescents had 2.05-fold (95% CI 1.23, 3.41) greater odds of treatment failure than non-reactant adolescents (p = 0.03). Adjusted risk of treatment failure was 14% (95% CI 3%, 28%) greater for each point elevation in reactance score (p = 0.016). Autonomy over medication-taking did not modify the association between reactance and treatment failure. Psychological reactance may be a useful interventional target for improving adolescent adherence.</p>
<p>Youth living with HIV (YLWH) are less likely than older adults to achieve and sustain viral suppression. While treatment guidelines recommend decreased viral load (VL) monitoring in individuals with well-controlled HIV, the appropriateness of this strategy for adolescents is unknown. We conducted a retrospective cohort study to describe longitudinal viral suppression and identify incidence of, and risk factors for, virologic failure among YLWH at a US adolescent HIV clinic from 2002 to 2015. We utilized Cox proportional hazards modeling to compare hazard ratios (HRs) for virologic failure stratified by baseline characteristics. Study participants (n = 365) were predominately African American (87%) and cisgender men and transgender women who have sex with men (80%) and the majority (79%) entered care from 2002 to 2012. Of antiretroviral therapy (ART)-treated participants (n = 201), 88% achieved viral suppression, with 29% subsequently developing virologic failure at a median 12.0 months [interquartile range (IQR) 6.9-22.4] after suppression. The cohort incidence rate of virologic failure was 200 (confidence interval [95% CI]: 151-264) per 1000 person years (PY), with a rate after ≥2 years sustained suppression of 113 (95% CI: 57-227) per 1000 PY. After adjusting for time to ART initiation, initial regimen class, and year of cohort entry, cisgender women had increased hazards of virologic failure (HR 3.2 95% CI: 1.3-7.9, p = 0.01). In conclusion, youth remained at high risk of virologic failure throughout their treatment course, with higher hazards of virologic failure among cisgender women compared with other youth. Maintaining frequent VL monitoring in YLWH may be warranted, even after prolonged viral suppression.</p>
<p><strong>INTRODUCTION: </strong>Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings.</p>
<p><strong>METHODS: </strong>In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described.</p>
<p><strong>RESULTS AND DISCUSSION: </strong>The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement.</p>
<p><strong>CONCLUSION: </strong>The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.</p>