Laura Gauer Bermudez

Equity in adherence to antiretroviral therapy among economically vulnerable adolescents living with HIV in Uganda

ABSTRACT Studies from sub-Saharan Africa indicate that children made vulnerable by poverty have been disproportionately affected by HIV with many exposed via mother-to-child transmission. For youth living with HIV, adherence to life-saving treatment regimens are likely to be affected by the complex set of economic and social circumstances that challenge their families and also exacerbate health problems. Using baseline data from the National Institute of Child and Human Development (NICHD) funded Suubi+Adherence study, we examined the extent to which individual and composite measures of equity predict self-reported adherence among Ugandan adolescents aged 10–16 (n = 702) living with HIV. Results showed that greater asset ownership, specifically familial possession of seven or more tangible assets, was associated with greater odds of self-reported adherence (OR 1.69, 95% CI: 1.00–2.85). Our analyses also indicated that distance to the nearest health clinic impacts youth’s adherence to an ARV regimen. Youth who reported living nearest to a clinic were significantly more likely to report optimal adherence (OR 1.49, 95% CI: 0.92–2.40). Moreover, applying the composite equity scores, we found that adolescents with greater economic advantage in ownership of household assets, financial savings, and caregiver employment had higher odds of adherence by a factor of 1.70 (95% CI: 1.07–2.70). These findings suggest that interventions addressing economic and social inequities may be beneficial to increase antiretroviral therapy (ART) uptake among economically vulnerable youth, especially in sub-Saharan Africa. This is one of the first studies to address the question of equity in adherence to ART among economically vulnerable youth with HIV.

Effects of Financial Incentives on Saving Outcomes and Material Well-Being: Evidence From a Randomized Controlled Trial in Uganda: Effects of Financial Incentives

The use of savings products to promote financial inclusion has increasingly become a policy priority across sub-Saharan Africa, yet little is known about how families respond to varying levels of savings incentives and whether the promotion of incentivized savings in low-resource settings may encourage households to restrict expenditures on basic needs. Using data from a randomized controlled trial in Uganda, we examine: 1) whether low-income households enrolled in an economic-empowerment intervention consisting of matched savings, workshops, and mentorship reduced spending on basic needs and 2) how varied levels of matching contributions affected household savings and consumption behavior. We compared primary school-attending AIDS-affected children (N = 1,383) randomized to a control condition with two intervention arms with differing savings-match incentives: 1:1 (Bridges) and 1:2 (Bridges PLUS). We found that: 1) 24 months post-intervention initiation, children in Bridges and Bridges PLUS were more likely to have accumulated savings than children in the control condition; 2) higher match incentives (Bridges PLUS) led to higher deposit frequency but not higher savings in the bank; 3) intervention participation did not result in material hardship; and 4) in both intervention arms, participating families were more likely to start a family business and diversify their assets.

Safety, trust, and disclosure: A qualitative examination of violence against refugee adolescents in Kiziba Camp, Rwanda

Refugee adolescents face increased vulnerability to child protection risks including abuse, neglect, violence, and exploitation. The aim of this qualitative study was to examine the nature of violence against adolescents in Kiziba Camp, Rwanda, using an ecological framework to analyze the factors that influence protection risks and abuse disclosure across multiple system levels. In order to understand these issues more comprehensively, a transgenerational inquiry sought perceptions from both adolescents and their caregivers. In April 2016, as part of a larger, comprehensive study on adolescent protection, 19 focus group discussions were conducted with a total of 70 adolescents and 68 caregivers from the Democratic Republic of Congo. A qualitative content analysis identified three salient themes. First, structural protection risks exist for adolescents in Kiziba Camp, with economic insecurity and resource constraints resulting in specific risks such as overcrowded housing and adolescents traveling for firewood collection. Second, intergenerational conflict between caregivers and adolescents was perceived to negatively influence abuse disclosure. Lastly, protection mechanisms and reporting pathways were underutilized as caregivers and adolescents expressed concern over the shame, embarrassment, and social rejection that characterized formal disclosure in Kiziba, often rooted in restrictive and inequitable gender norms. These findings suggest that efforts at child protection should be multi-faceted and address structural aspects of risk; household levels of communication and trust; and societal norms that deter abuse reporting. The study also underscores the need for further research on risk and protective factors in camp settings to better tailor interventions aiming to reduce violence against children.

HIV Risk Among Displaced Adolescent Girls in Ethiopia: the Role of Gender Attitudes and Self-Esteem

Adolescent girls in sub-Saharan Africa have been deemed one of the most critical populations to address in the campaign for an HIV-free generation. Experiences of intimate partner violence (IPV), harmful gender norms, diminished personal agency, and age-disparate sex have been identified as factors in the increasing rate of new infections among this population. Using baseline data from a cluster-randomized controlled trial in three refugee camps in Benishangul-Gumuz Regional State in Ethiopia, our study quantitatively examined the associations between HIV risk factors, attitudes on gender inequality, IPV acceptability, and self-esteem for female adolescent refugees primarily from Sudan and South Sudan (n = 919). In multivariate models, adjusting for age and education, results showed girls who were more accepting of gender inequitable norms and IPV had greater odds of ever experiencing forced (OR 1.40, CI 1.15–1.70; OR 1.66, CI 1.42–1.94) or transactional sex (OR 1.28, CI 1.05–1.55; OR 1.59, CI 1.37–1.85) compared to girls who demonstrated less approval. Higher self-esteem was associated with increased odds of condom use (OR 1.13, CI 1.02–1.24) as well as decreased odds of adolescent marriage (OR 0.93, CI 0.90–0.95), age-disparate sex (OR 0.90, CI 0.86–0.94), and transactional sex (OR 0.96, CI 0.93–0.99). The findings suggest acceptance of inequitable gender norms (including those that perpetuate violence against women) and low self-esteem to be associated with common HIV risk factors among refugee adolescents living in Ethiopia. Greater attention towards the intersections of gender equality and self-valuation is needed when seeking to understand HIV risk among refugee adolescent girls in sub-Saharan Africa.

Setting global research priorities for child protection in humanitarian action: Results from an adapted CHNRI exercise

Background Armed conflict, natural disaster, and forced displacement affect millions of children each year. Such humanitarian crises increase the risk of family separation, erode existing support networks, and often result in economic loss, increasing children’s vulnerability to violence, exploitation, neglect, and abuse. Research is needed to understand these risks and vulnerabilities and guide donor investment towards the most effective interventions for improving the well-being of children in humanitarian contexts. Methods The Assessment, Measurement & Evidence (AME) Working Group of the Alliance for Child Protection in Humanitarian Action (ACPHA) identified experts to participate in a research priority setting exercise adapted from the Child Health and Nutrition Research Initiative (CHNRI). Experts individually identified key areas for research investment which were subsequently ranked by participants using a Likert scale. Research Priority Scores (RPS) and Average Expert Agreement (AEA) were calculated for each identified research topic, the top fifteen of which are presented within this paper. Results Intervention research, which aims to rigorously evaluate the effectiveness of standard child protection activities in humanitarian settings, ranked highly. Child labor was a key area of sector research with two of the top ten priorities examining the practice. Respondents also prioritized research efforts to understand how best to bridge humanitarian and development efforts for child protection as well as identifying most effective way to build the capacity of local systems in order to sustain child protection gains after a crisis. Conclusions Rigorous, scientific research that assesses the scope of child protection risks, examines the effectiveness of interventions to improve child well-being, and translates evidence to practice is critical. Findings from this research priority setting exercise offer guidance for a global research agenda on child protection in humanitarian settings, encouraging cooperation among donors, implementers, and academics to pursue a coordinated approach to evidence generation.

Understanding female migrant child labor within a cumulative risk framework: The case for combined interventions in Ghana

North-to-south migration has been a persistent trend in Ghana. Yet the migrating population has recently shifted to become predominantly female and younger, with a significant increase in rural adolescent girls seeking employment in urban and peri-urban areas. For adolescents without strong networks of social and financial support, this practice can jeopardize their physical and mental health, putting them at risk of sexual victimization and economic exploitation. Building upon the work of cumulative risk and ecological systems theorists, this article examines the case of female adolescent load bearers (Kayayei) in Ghana, highlighting the need to develop and evaluate multi-component prevention efforts.

Does Economic Strengthening Improve Viral Suppression Among Adolescents Living with HIV? Results From a Cluster Randomized Trial in Uganda

To assess the effect of a savings-led economic empowerment intervention on viral suppression among adolescents living with HIV. Using data from Suubi + Adherence, a longitudinal, cluster randomized trial in southern Uganda (2012–2017), we examine the effect of the intervention on HIV RNA viral load, dichotomized between undetectable (< 40 copies/ml) and detectable (≥ 40 copies/ml). Cluster-adjusted comparisons of means and proportions were used to descriptively analyze changes in viral load between study arms while multi-level modelling was used to estimate treatment efficacy after adjusting for fixed and random effects. At 24-months post intervention initiation, the proportion of virally suppressed participants in the intervention cohort increased tenfold (ΔT2−T0 = + 10.0, p = 0.001) relative to the control group (ΔT2−T0 = + 1.1, p = 0.733). In adjusted mixed models, simple main effects tests identified significantly lower odds of intervention adolescents having a detectable viral load at both 12- and 24-months. Interventions addressing economic insecurity have the potential to bolster health outcomes, such as HIV viral suppression, by improving ART adherence among vulnerable adolescents living in low-resource environments. Further research and policy dialogue on the intersections of financial security and HIV treatment are warranted.

Informing health choices in low-resource settings

Because of the abundance of health information, available via multiple sources, it is important that individuals be able to critically appraise health claims to make well informed decisions. This is of even greater importance in low-income countries where individuals cannot afford to invest in ineffective treatments. Indeed, public health practitioners have long touted the importance of health education; for example, a variety of well tested and updated curricula to prevent adolescent pregnancy and HIV have shown positive health outcomes across low-income and high-income communities. Yet, these efforts have typically focused on behavioural practices, rather than the skills necessary to make sense of a seemingly limitless amount of health information. As the digital age is enhancing the speed and frequency with which we are able to access reliable health information, so too does it perpetuate the spread of misinformation. Communication platforms such as television, radio, and increasingly non-traditional platforms, including social media and internet search engines, offer rapid dissemination of both accurate and inaccurate guidance on preventive and curative health interventions. When the sharing of health guidance is done by dependable and verifiable sources, mass dissemination can have a positive effect on health behaviours. Conversely, non-scientific claims can quickly proliferate, negatively affecting health-care use and health outcomes for those who are unable to critically analyse available information and discern fact from fiction. From the spread of antivaccination claims via social and internet media, to continued battles against AIDS denialism, health misinformation abounds. In The Lancet, Allen Nsangi and colleagues and Daniel Semakula and colleagues extend such findings by testing an intervention that teaches health literacy in Uganda, including how to assess the reliability of health treatment claims. The two articles evaluate the effectiveness of the Informed Health Choices schoolbased intervention aimed at primary school children (ages 10–12 years) and a podcast aimed at their parents. Children in early adolescence are a vital age group in which to build critical-thinking techniques. Equally, parents remain an important audience because they are responsible for the health decisions of the household and model health-seeking behaviours for their children. In Nsangi and colleagues’ cluster randomised trial, 120 eligible schools were randomly assigned to the Informed Health Choices study group in which they received textbooks, exercise books, and a teachers’ guide (60 schools, 76 teachers, and 6383 children) or to the control group in which they did not receive the intervention (60 schools, 67 teachers, and 4430 children). During nine 80 min lessons, provided over the course of one school term, teachers trained students on 12 concepts essential to assessing claims about treatment effects and making informed health choices. The primary outcomes included the mean score on an examination, with two multiple-choice questions representing each of the 12 concepts, and the proportion of students with a passing score. In Semakula and colleagues’ randomised controlled trial, 675 parents of children taking part in Nsangi and colleagues’ trial were assigned to listen to either the Informed Health Choices podcast (n=344) or typical public service announcements about health issues (control group, n=341). The primary outcomes were again the mean score on an examination, with two multiple-choice questions representing key concepts necessary for assessing health claims (18 questions in total), and the proportion of parents with passing scores on the test. The two trials assessed the ability of students and their parents to successfully analyse claims about the Published Online May 21, 2017 http://dx.doi.org/10.1016/ S0140-6736(17)31290-4