Child Care Feeding Programs Associated With Food Security and Health for Young Children From Families With Low Incomes.

BACKGROUND: The Child and Adult Care Food Program is the primary national program that enables child-care settings to provide healthy meals for children. Associations between Child and Adult Care Food Program participation and child health and development and health care utilization are understudied. OBJECTIVE: To assess associations between children's health, development, health care utilization and food security by meal source (child-care-provided vs parent-provided) among children from low-income families with a child care subsidy attending child-care in settings likely eligible to participate in Child and Adult Care Food Programs. DESIGN: The study used repeat cross-sectional surveys (new sample at successive time points) conducted year-round. PARTICIPANTS AND SETTING: Primary caregivers of 3,084 young children accessing emergency departments or primary care in Baltimore, MD; Boston, MA; Little Rock, AR; Minneapolis, MN; and Philadelphia, PA, were interviewed between 2010 and 2020. The sample was limited to children aged 13 to 48 months, receiving a child care subsidy and attending child-care centers or family child-care homes ≥20 hours per week. MAIN OUTCOME MEASURES: Outcomes included household and child food security; child health, growth, and developmental risk; and admission to the hospital on the day of the emergency department visit. STATISTICAL ANALYSES: Meal source and participant characteristics were analyzed using χ2 tests; associations of outcomes with parent-provided meals were analyzed with adjusted logistic regression. RESULTS: The majority of children had child-care-provided meals (87.2% child-care-provided vs 12.8% parent-provided). Compared with children with parent-provided meals, children with child-care-provided meals had lower adjusted odds of living in a food-insecure household (adjusted odds ratio 0.70, 95% CI 0.55 to 0.88), being in fair or poor health (adjusted odds ratio 0.61, 95% CI 0.46 to 0.81), or hospital admission from the emergency department (adjusted odds ratio 0.59, 95% CI 0.41 to 0.83), with no differences in growth or developmental risk. CONCLUSIONS: Compared with meals provided from home, child-care-provided meals likely supported by the Child and Adult Care Food Program are related to food security, early childhood health, and reduced hospital admissions from an emergency department among low-income families with young children.

Eviction and Household Health and Hardships in Families With Very Young Children.

BACKGROUND: Families with versus without children are at greater eviction risk. Eviction is a perinatal, pediatric, and adult health concern. Most studies evaluate only formal evictions. METHODS: Using cross-sectional surveys of 26 441 caregiver or young child (<48 months) dyads from 2011 to 2019 in emergency departments (EDs) and primary care clinics, we investigated relationships of 5 year history of formal (court-involved) and informal (not court-involved) evictions with caregiver and child health, history of hospitalizations, hospital admission from the ED on the day of the interview, and housing-related and other material hardships. RESULTS: 3.9% of 26 441 caregivers reported 5 year eviction history (eviction), of which 57.0% were formal evictions. After controlling for covariates, we found associations were minimally different between formal versus informal evictions and were, therefore, combined. Compared to no evictions, evictions were associated with 1.43 (95% CI: 1.17-1.73), 1.55 (95% confidence interval [CI]: 1.32-1.82), and 1.24 (95% CI: 1.01-1.53) times greater odds of child fair or poor health, developmental risk, and hospital admission from the ED, respectively, as well as adverse caregiver and hardship outcomes. Adjusting separately for household income and for housing-related hardships in sensitivity analyses did not significantly alter results, although odds ratios were attenuated. Hospital admission from the ED was no longer significant. CONCLUSIONS: Demonstrated associations between eviction and health and hardships support broad initiatives, such as housing-specific policies, income-focused benefits, and social determinants of health screening and community connections in health care settings. Such multifaceted efforts may decrease formal and informal eviction incidence and mitigate potential harmful associations for very young children and their families.

Prenatal WIC Is Associated with Increased Birth Weight of Infants Born in the United States with Immigrant Mothers.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) improves health outcomes for participating mothers and children. Recent immigration policy changes increased chilling effects on WIC access and utilization. Associations between WIC participation and neonatal outcomes among infants born to immigrant parents-23% of all births in the United States-are understudied. OBJECTIVE: Our aim was to examine relationships between prenatal participation in WIC and birth weight among infants of income-eligible immigrant mothers. DESIGN: The study design was repeat cross-sectional in-person surveys. PARTICIPANTS/SETTING: Participants were 9,083 immigrant mothers of publicly insured or uninsured US-born children younger than 48 months accessing emergency departments or primary care in Baltimore, MD; Boston, MA; Little Rock, AR; Minneapolis, MN; and Philadelphia, PA interviewed from 2007 through 2017. MAIN OUTCOME MEASURES: Outcomes were mean birth weight (in grams) and low birth weight (<2,500 g). STATISTICAL ANALYSES: Multivariable linear regression assessed associations between prenatal WIC participation and mean birth weight; multivariable logistic regression examined association between prenatal WIC participation and low birth weight. RESULTS: Most of the immigrant mothers (84.6%) reported prenatal WIC participation. Maternal ethnicities were as follows: 67.4% were Latina, 27.0% were Black non-Latina, 2.2% were White non-Latina, and 3.5% were other/multiple races non-Latina. Infants of prenatal WIC-participant immigrant mothers had higher adjusted mean birth weight (3,231.1 g vs 3,149.8 g; P < .001) and lower adjusted odds of low birth weight (adjusted odds ratio 0.79, 95% CI 0.65 to 0.97; P = .02) compared with infants of nonparticipants. Associations were similar among groups when stratified by mother's length of stay in United States. CONCLUSIONS: Prenatal WIC participation for income-eligible immigrant mothers is associated with healthier birth weights among infants born in the United States, including for those who arrived most recently.

Lack of Association Between Recent Cannabis Use and Advanced Liver Fibrosis Among HIV-positive Heavy Drinkers.

AIM: This study aimed to analyze the association between any past-month cannabis use and advanced liver fibrosis. BACKGROUND: Cannabinoid receptors play a role in acute and chronic liver injury, but human studies addressing the impact of cannabis use on liver fibrosis have shown mixed results. OBJECTIVE: The objective of this study was to explore and estimate the association between pastmonth cannabis use and advanced liver fibrosis (ALF) in a cohort of Russian HIV-positive individuals with heavy alcohol use and a high prevalence of hepatitis C virus (HCV) coinfection. METHODS: Baseline data were analyzed from participants of the ZINC study, a trial that enrolled HIV-positive Russian patients without prior antiretroviral therapy. Cannabis use during the prior month was assessed at study entry. ALF was defined as FIB-4>3.25 and APRI>1.5. Transient elastography was used to detect advanced liver fibrosis among participants with FIB-4 values in the intermediate range (between 1.45 and 3.25). RESULTS: Participants (n=248) were mostly male (72.6%), young (median age of 33.9 years), infected with HCV (87.9%), and did not have advanced immunosuppression (median CD4 count 465). Cannabis use was uncommon (12.4%), and the prevalence of advanced liver disease was 21.7%. The prevalence of ALF was similar among those who used cannabis compared to those who did not (25.8% vs. 21.7%). We were unable to detect an association between cannabis use and ALF (adjusted odds ratio: 1.28, 95% confidence interval: 0.53-3.12, p=0.59) in logistic regression models adjusting for age, sex, heavy drinking, BMI, and CD4 cell count. CONCLUSION: In this exploratory study among HIV-positive heavy drinking Russians, we did not detect an association between recent cannabis use and ALF. Larger scale studies, including more participants with cannabis use, are needed to examine this relationship further.

Alcohol policies, firearm policies, and suicide in the United States: a lagged cross-sectional study.

BACKGROUND: Alcohol and firearms are commonly involved in suicide in the United States. State alcohol and firearm policies may impact alcohol and firearm related suicide, yet little is known about these relationships. This study examines relationships between state alcohol and firearm policies and suicides involving alcohol, guns, or both, and explores interactive policy associations. METHODS: Alcohol policies were assessed with the Alcohol Policy Scale. Firearm policies were assessed using the Gun Law Scorecard from Giffords Law Center. Suicide data from the National Violent Death Reporting System in 2015 covered 22 states. State- and individual-level GEE Poisson and logistic regression models assessed relationships between policies and firearm- and/or alcohol-involved suicides with a 1-year lag. RESULTS: In 2015, there were 8996 suicide deaths with blood alcohol concentration test results in the 22 included states. Of those deaths, alcohol and/or firearms were involved in 5749 or 63.9%. Higher alcohol and gun law scores were associated with reduced incidence rates and odds of suicides involving either alcohol or firearms (adjusted incidence rate ratios [IRR] 0.72 (95% CI 0.63, 0.83) for alcohol policies, 0.86 (95% CI 0.82, 0.90) for firearm policies). Relationships were similar for suicides involving both alcohol and firearms, and there was an interactive effect, such that states with restrictive policies for both had the lowest rates of suicides involving alcohol or guns. CONCLUSIONS: More restrictive alcohol and firearm policies are associated with lower rates and odds of suicides involving alcohol or firearms, and alcohol and firearms, and may be a promising means by which to reduce suicide.

Effect of Zinc Supplementation vs Placebo on Mortality Risk and HIV Disease Progression Among HIV-Positive Adults With Heavy Alcohol Use: A Randomized Clinical Trial.

Importance: Zinc supplementation can reduce alcohol-related microbial translocation and inflammation. Objective: To assess whether zinc supplementation reduces markers of mortality and risk of cardiovascular disease, reduces levels of inflammation and microbial translocation, and slows HIV disease progression in people with heavy alcohol use who are living with HIV/AIDS. Design, Setting, and Participants: This study is a double-blinded placebo-controlled randomized clinical trial of zinc supplementation among participants recruited from 2013 to 2015. Participants were recruited from HIV and addiction clinical and nonclinical care sites in St Petersburg, Russia. Participants were adults (aged 18-70 years) with documented HIV infection who were antiretroviral therapy-naive at baseline and had past 30-day heavy alcohol consumption. Data analysis was performed from February 2017 to February 2020. Intervention: Pharmacy-grade zinc gluconate supplementation (15 mg for men and 12 mg for women, taken daily by mouth for 18 months) was compared with a placebo. Main Outcomes and Measures: The primary outcome was mortality risk measured as a change in Veterans Aging Cohort Study (VACS) Index score between baseline and 18 months. The VACS Index scores range from 0 to 164, with higher scores indicating higher mortality risk. Secondary outcomes were change in CD4 cell count between baseline and 18 months, the assessment of cardiovascular disease risk (Reynolds Risk Score, which ranges from 0% to 100%, with higher scores indicating higher risk), and changes in inflammatory or microbial translocation biomarkers at 18 months. Adjusted linear regression analyses were performed. Results: A total of 254 participants (184 men [72%]; mean [SD] age, 34 [6] years) were enrolled in the trial; 126 were randomized to receive zinc, and 128 were randomized to receive placebo. Participants had high CD4 cell counts (mean [SD], 521 [292] cells/mm3), and 188 (74%) reported heavy drinking in the past week. In the main analyses, zinc supplementation did not affect changes in the VACS Index score at 18 months (change for zinc, mean [SD], 0.49 [14.6]; median [interquartile range], 0.0 [-7.0 to 6.0]; change for placebo, mean [SD], 5.5 [17.2]; median [interquartile range], 6.0 [-6.0 to 14.0]; adjusted mean difference [AMD], -4.68; 95% CI, -9.62 to 0.25; P = .06) or any secondary outcomes, including change in CD4 cell count (AMD, 41.8 cells/mm3; 95% CI, -20.3 to 103.8 cells/mm3; P = .19), Reynolds Risk Score (AMD, -0.014; 95% CI, -0.167 to 0.139; P = .85), interleukin-6 level (AMD, -0.13 pg/mL; 95% CI, -0.38 to 0.11 pg/mL; P = .30), dimerized plasmin fragment D level (AMD, -0.21 µg/mL fibrinogen equivalent units; 95% CI, -0.48 to 0.07 µg/mL fibrinogen equivalent units; P = .14), soluble CD14 level (AMD, -38.01 ng/mL; 95% CI, -166.90 to 90.88 ng/mL; P = .56), intestinal fatty acid binding protein level (AMD, 0.08 pg/mL; 95% CI, -0.07 to 0.22 pg/mL; P = .32), and lipopolysaccharide binding protein level (AMD, -0.09 ng/mL; 95% CI, -0.23 to 0.06 ng/mL; P = .24). In the per-protocol analyses, zinc supplementation statistically significantly affected changes in the VACS Index score at 18 months (AMD, -7.49; 95% CI, -13.74 to -1.23; P = .02); however, the adherence rate to zinc supplementation was 51%. Conclusions and Relevance: Zinc supplementation did not reduce mortality risk, CD4 cell counts, cardiovascular disease risk, and levels of inflammation or microbial translocation in people with heavy alcohol use who are living with HIV/AIDS. Zinc supplementation did not change the VACS Index score but may have been limited by low adherence. Trial Registration: ClinicalTrials.gov Identifier: NCT01934803.

Maternal Place of Birth, Socioeconomic Characteristics, and Child Health in US-Born Latinx Children in Boston.

OBJECTIVE: Among US-born children of Latina US (USB) and Latina foreign-born mothers (FBM), to determine whether 1) household and child characteristics differ; 2) child health outcomes differ; 3) these differences diminish for children of FBM with longer duration of residence in the United States; and 4) these differences can be explained by food insecurity (FI) or by Supplemental Nutrition Assistance Program (SNAP) participation. METHODS: Cross-sectional survey of 2145 Latina mothers of publicly insured US-born children 0 to 48 months old in a Boston emergency department (ED) 2004 to 2013. Predictors were FBM versus USBM and duration of residence in the United States. Outcomes were mothers' report of child health, history of hospitalization, developmental risk, and hospital admission on the day of ED visit. Multivariable logistic regression adjusted for potential confounders and effect modification. RESULTS: FBM versus USBM households had more household (31% vs 26%) and child (19% vs 11%) FI and lower SNAP participation (44% vs 67%). Children of FBM versus USBM were more likely to be reported in fair/poor versus good/excellent health (adjusted odds ratios 1.9, 95% confidence interval [1.4, 2.6]), with highest odds for children of FBM with shortest duration of residence, and to be admitted to the hospital on the day of the ED visit (adjusted odds ratios 1.7, 95% confidence interval [1.3, 2.2]). SNAP and FI did not fully explain these outcomes. CONCLUSION: When providing care and creating public policies, clinicians and policymakers should consider higher rates of food insecurity, lower SNAP participation, and risk for poor health outcomes in Latinx children of FBM.

SNAP, Young Children's Health, and Family Food Security and Healthcare Access.

INTRODUCTION: The Supplemental Nutrition Assistance Program (SNAP) is the largest nutrition assistance program in the U.S. This study's objective was to examine the associations between SNAP participation and young children's health and development, caregiver health, and family economic hardships. METHODS: Cross-sectional data from 2006 to 2016 were analyzed in 2017 for families with children aged <3 years in 5 cities. Generalized estimating equations and logistic regression were used to evaluate the associations of SNAP participation with child and caregiver health outcomes and food insecurity, forgone health care, and health cost sacrifices. Nonparticipants that were likely to be eligible for SNAP were compared with SNAP participants and analyses adjusted for covariates including Consumer Price Index for food to control for site-specific food prices. RESULTS: The adjusted odds of fair or poor child health status (AOR=0.92, 95% CI=0.86, 0.98), developmental risk (AOR=0.82, 95% CI=0.69, 0.96), underweight, and obesity in children were lower among SNAP participants than among nonparticipants. In addition, food insecurity in households and among children, and health cost sacrifices were lower among SNAP participants than among nonparticipants. CONCLUSIONS: Participation in SNAP is associated with reduced household and child food insecurity, lower odds of poor health and growth and developmental risk among infants and toddlers, and reduced hardships because of healthcare costs for their families. Improved SNAP participation and increased SNAP benefits that match the regional cost of food may be effective preventive health strategies for promoting the well-being of families with young children.

Food Insecurity, Health, and Development in Children Under Age Four Years.

BACKGROUND AND OBJECTIVES: Food insecurity and pediatric obesity affect young children. We examine how food insecurity relates to obesity, underweight, stunting, health, and development among children <4 years of age. METHODS: Caregivers of young children participated in a cross-sectional survey at medical centers in 5 US cities. Inclusion criteria were age of <48 months. Exclusion criteria were severely ill or injured and private health insurance. The Household Food Security Survey Module defined 3 exposure groups: food secure, household food insecure and child food secure, and household food insecure and child food insecure. Dependent measures were obesity (weight-age >90th percentile), underweight (weight-age <5th percentile), stunting (height/length-age <5th percentile), and caregiver-reported child health and developmental risk. Multivariable logistic regression analyses, adjusted for demographic confounders, maternal BMI, and food assistance program participation examined relations between exposure groups and dependent variables, with age-stratification: 0 to 12, 13 to 24, 25 to 36, and 37 to 48 months of age. RESULTS: Within this multiethnic sample (N = 28 184 children, 50% non-Hispanic African American, 34% Hispanic, 14% non-Hispanic white), 27% were household food insecure. With 1 exception at 25 to 36 months, neither household nor child food insecurity were associated with obesity, underweight, or stunting, but both were associated with increased odds of fair or poor health and developmental risk at multiple ages. CONCLUSIONS: Among children <4 years of age, food insecurity is associated with fair or poor health and developmental risk, not with anthropometry. Findings support American Academy of Pediatrics recommendations for food insecurity screening and referrals to help families cope with economic hardships and associated stressors.

Housing Instability Among Families With Young Children With Special Health Care Needs.

BACKGROUND AND OBJECTIVE: Children with special health care needs (SHCNs) have significant medical and educational expenses affecting household finances. Housing instability can be detrimental to family well-being. Our objective was to evaluate housing instability in households of children with and without SHCNs. METHODS: Cross-sectional surveys (2013-2017) in English and Spanish of caregivers with children <4 years old were conducted at 5 hospitals. The children with SHCN screener and caregiver report of child Supplemental Security Income (SSI) receipt were used to categorize children into the following groups: (1) no SHCNs, (2) SHCNs and no SSI, or (3) SHCNs and receiving SSI. Housing instability was determined by positive endorsement of ≥1 adverse circumstance: behind on rent or mortgage, or moving twice or more in the past year, or homelessness in the child's lifetime. Analyses used multivariable logistic regression models, adjusting for demographics and housing subsidies. RESULTS: Of 14 188 children, 80% had no SHCNs, 16% had SHCNs and no SSI, and 4% had SHCNs and received SSI. Compared with the no-SHCNs group, the SHCNs-no-SSI group but not the SHCN-receiving-SSI group experienced significantly greater adjusted odds of being behind on rent or mortgage (adjusted odds ratio [aOR] 1.28 [95% confidence interval (CI) 1.14-1.44]; P < .001), multiple moves (aOR 1.29 [95% CI 1.05-1.59]; P = .01), and homelessness (aOR 1.44 [95% CI 1.20-1.72]; P < .001). CONCLUSIONS: Families of children with SHCNs are at risk for housing instability. Child SSI receipt decreased the risk of housing instability among families of children with SHCNs. Protecting families of young children with SHCNs from housing instability is an important investment.

Alcohol Policies and Alcohol Involvement in Intimate Partner Homicide in the U.S.

INTRODUCTION: Intimate partner violence (IPV) results in deaths of both primary and corollary (i.e., nonintimate partner) victims. Alcohol use is a known risk factor for IPV, yet the relationship between alcohol policies and IPV homicides is unclear. This repeated cross-sectional study characterizes alcohol involvement, and the relationship between alcohol policies and alcohol involvement, among victims of IPV homicides in the U.S. METHODS: Homicide victim data from 17 states in the National Violent Death Reporting System from 2003 to 2012 were analyzed in 2017-2018. Alcohol Policy Scale scores characterized alcohol policies by state year and were used in generalized estimating equation logistic regression models to predict the odds of alcohol involvement among victims of IPV homicide. RESULTS: Among victims of IPV homicide, 36.5% of primary and 41.1% of corollary victims had a blood alcohol concentration (BAC) >0.00%. Of the victims with a positive BAC, 67.6% had a BAC ≥0.08%. In adjusted models, a 10-percentage point increase in Alcohol Policy Scale score was associated with reduced odds of having a positive BAC (AOR=0.77, 95% CI=0.64, 0.93) and having a BAC ≥0.08% (AOR=0.82, 95% CI=0.68, 0.99) among all victims, primary victims (AOR=0.78, 95% CI=0.63, 0.98; AOR=0.82, 95% CI=0.65, 1.04), and corollary victims (AOR=0.61, 95% CI=0.42, 0.89; AOR=0.68, 95% CI=0.48, 0.97). CONCLUSIONS: Alcohol use was prevalent among victims of IPV homicide, and more-restrictive alcohol policies were associated with reduced odds of alcohol involvement. Strengthening alcohol policies is a promising strategy to reduce alcohol-involved IPV homicide victimization.

Loss Of SNAP Is Associated With Food Insecurity And Poor Health In Working Families With Young Children.

The Supplemental Nutrition Assistance Program (SNAP) helps working families meet their nutritional needs. Families whose earned income increases in a given month may have their SNAP benefits abruptly reduced or cut off in the following month. Using sentinel sample data from 2007-15 for families with children younger than age four, we investigated how SNAP benefit reductions or cutoffs resulting from increased income were related to economic hardships (food and energy insecurity, unstable housing, forgone health and/or dental care, and health cost sacrifices) and to caregiver and child health. After we controlled for covariates, we found that the groups whose SNAP benefits were reduced or cut off had significantly increased odds of household and child food insecurity, compared to a group with consistent participation in SNAP. Reduced benefits were associated with 1.43 and 1.22 times greater odds of fair or poor caregiver and child health, respectively. Policy modifications to smooth changes in benefit levels as work incomes improve may protect working families with young children from increased food insecurity, poor health, and forgone care.

Subclinical tuberculosis among adults with HIV: clinical features and outcomes in a South African cohort.

BACKGROUND: Subclinical tuberculosis is an asymptomatic disease phase with important relevance to persons living with HIV. We describe the prevalence, clinical characteristics, and risk of mortality for HIV-infected adults with subclinical tuberculosis. METHODS: Untreated adults with HIV presenting for outpatient care in Durban, South Africa were screened for tuberculosis-related symptoms and had sputum tested by acid-fast bacilli smear and tuberculosis culture. Active tuberculosis and subclinical tuberculosis were defined as having any tuberculosis symptom or no tuberculosis symptoms with culture-positive sputum. We evaluated the association between tuberculosis disease category and 12-month survival using Cox regression, adjusting for age, sex, and CD4 count. RESULTS: Among 654 participants, 96 were diagnosed with active tuberculosis disease and 28 with subclinical disease. The median CD4 count was 68 (interquartile range 39-161) cells/mm3 in patients with active tuberculosis, 136 (72-312) cells/mm3 in patients with subclinical disease, and 249 (125-394) cells/mm3 in those without tuberculosis disease (P < 0.001). The proportion of smear positive cases did not differ significantly between the subclinical (29%) and active tuberculosis groups (14%, P 0.08). Risk of mortality was not increased in individuals with subclinical tuberculosis relative to no tuberculosis (adjusted hazard ratio 0.84, 95% confidence interval 0.26-2.73). CONCLUSIONS: Nearly one-quarter of tuberculosis cases among HIV-infected adults were subclinical, which was characterized by an intermediate degree of immunosuppression. Although there was no significant difference in survival, anti-tuberculous treatment of subclinical cases was common. TRIAL REGISTRATION: Prospectively registered on ClinicalTrials.gov , NCT01188941 (August 26, 2010).

Nitrate measurement in droplet flow: gas-mediated crosstalk and correction.

In droplet microfluidics, droplets have traditionally been considered discrete self-contained reaction chambers, however recent work has shown that dissolved solutes can transfer into the oil phase and migrate into neighbouring droplets under certain conditions. The majority of reports on such inter-droplet "crosstalk" have focused on surfactant-driven mechanisms, such as transport within micelles. While trialling a droplet-based system for quantifying nitrate in water, we encountered crosstalk driven by a very different mechanism: conversion of the analyte to a gaseous intermediate which subsequently diffused between droplets. Importantly we found that the crosstalk occurred predictably, could be experimentally quantified, and measurements rationally post-corrected. This showed that droplet microfluidic systems susceptible to crosstalk such as this can nonetheless be used for quantitative analysis.

Design of a randomized controlled trial of zinc supplementation to improve markers of mortality and HIV disease progression in HIV-positive drinkers in St. Petersburg, Russia.

Background Russia continues to have an uncontrolled HIV epidemic and its per capita alcohol consumption is among the highest in the world. Alcohol use among HIV-positive individuals is common and is associated with worse clinical outcomes. Alcohol use and HIV each lead to microbial translocation, which in turn results in inflammation. Zinc supplementation holds potential for lowering levels of biomarkers of inflammation, possibly as a consequence of its impact on intestinal permeability. This paper describes the protocol of a double-blinded randomized placebo-controlled trial of zinc supplementation in St. Petersburg, Russia. Methods Participants (n = 254) were recruited between October 2013 and June 2015 from HIV and addiction clinical care sites, and non-clinical sites in St. Petersburg, Russia. Participants were randomly assigned, to receive either zinc (15 mg for men; 12 mg for women) or placebo, daily for 18 months. The following outcomes were assessed at 6, 12, and 18 months: (1) mortality risk (primary outcome at 18 months); (2) HIV disease progression; (3) cardiovascular risk; and (4) microbial translocation and inflammation. Adherence was assessed using direct (riboflavin) and indirect (pill count, self-report) measures. Conclusion Given the limited effectiveness of current interventions to reduce alcohol use, zinc supplementation merits testing as a simple, low-cost intervention to mitigate the consequences of alcohol use in HIV-positive persons despite ongoing drinking.

False-positive HIV diagnoses: lessons from Ugandan and Russian research cohorts.

BACKGROUND: Research studies rely on accurate assessment of entry criteria in order to maintain study integrity and participant safety, however, challenges can exist with HIV studies in international settings. OBJECTIVE: Examine the unexpectedly high proportion of study participants with an undetectable HIV viral load found in Ugandan and Russian research cohorts meeting antiretroviral therapy (ART)-naïve entry criteria. METHODS: Russian participants with documented HIV and ART-naïve status were recruited between 2012 and 2015 from clinical and non-clinical sites in St. Petersburg. Participants in Uganda were recruited from Mbarara Regional Referral Hospital from 2011 to 2014 with documented HIV infection via rapid diagnostic testing and recorded ART-naïve in the clinic database. HIV viral load testing of baseline samples was performed; the lower limit of detection was 500 copies/mL in Russia and 40 in Uganda. Due to an unexpectedly high proportion of participants with undetectable viremia, additional tests were performed: enzyme-linked immunosorbent assay HIV testing and testing for ART. RESULTS: In Russia, 16% (58/360) had undetectable viremia; 3% (9/360) re-tested HIV-seronegative and 4% (13/360) tested positive for ART. In Uganda 11% (55/482) had undetectable viremia; 5% (26/482) re-tested HIV-seronegative, while <1% (4/482) tested positive for ART. CONCLUSIONS: In both Russia & Uganda, undetectable viremia was much higher than would be expected for an HIV-infected ART-naïve cohort. Misclassification of study participants was due to misdiagnosis of HIV with rapid diagnostic testing and inaccurate accounting of ART use. Confirmatory HIV testing could improve accuracy of participants meeting entry criteria for HIV infection as might increased scrutiny of medication use in an ART-naïve cohort.

Unstable Housing and Caregiver and Child Health in Renter Families.

OBJECTIVES: To evaluate how 3 forms of housing instability relate to caregiver and child health among low-income renter households. METHODS: Caregivers of children 0 to 48 months of age were interviewed in 5 urban medical centers from May 2009 to December 2015. Caregivers reported on the following: caregiver health, maternal depressive symptoms, child's health, lifetime hospitalizations, developmental risk, and 3 housing circumstances, which were categorized as being behind on rent in the past 12 months, multiple moves (≥ 2 in past 12 months), and child's lifetime history of homelessness. Associations with caregiver and child health outcomes were examined through multivariable logistic regression. RESULTS: Of 22 324 families, 34% had at least 1 of the following adverse housing circumstances: 27% had been behind on rent, 8% had made multiple moves, and 12% had a history of being homeless. Overlap between these was limited; 86% experienced only 1 adverse housing circumstance. Each circumstance was individually associated with increased adjusted odds of adverse health and material hardship compared with stable housing. Households behind on rent had increased adjusted odds of fair and/or poor caregiver health (adjusted odds ratio [aOR]: 1.91; 95% confidence interval [CI]: 1.77-2.05), maternal depressive symptoms (aOR: 2.71; 95% CI: 2.51-2.93), child lifetime hospitalizations (aOR: 1.19; 95% CI: 1.10-1.27), fair and/or poor child health (aOR: 1.41; 95% CI: 1.28-1.56), and household material hardships. Families with multiple moves and history of homelessness had similar adverse caregiver, child, health, and hardship outcomes. CONCLUSIONS: Three forms of housing instability were associated with adverse caregiver and child health among low-income renter households. The American Academy of Pediatrics recommends social screening within health care; providers could consider assessing for behind on rent, multiple moves, and homelessness in high-risk practices.

Use of an android phone application for automated text messages in international settings: A case study in an HIV clinical trial in St. Petersburg, Russia.

BACKGROUND/AIMS: Reproducible outcomes in clinical trials depend on adherence to study protocol. Short message service (also known as text message) reminders have been shown to improve clinical trial adherence in the United States and elsewhere. However, due to systematic differences in mobile data plans, languages, and technology, these systems are not easily translated to international settings. METHODS: To gauge technical capabilities for international projects, we developed SMSMessenger, an automated Android application that uses a US server to send medication reminders to participants in a clinical trial in St. Petersburg, Russia (Zinc for HIV disease among alcohol users-a randomized controlled trial in the Russia Alcohol Research Collaboration on HIV/AIDS cohort). The application is downloaded once onto an Android study phone. When it is time for the text message reminders to be sent, study personnel access the application on a local phone, which in turn accesses the existing clinical trial database hosted on a US web server. The application retrieves a list of participants with the following information: phone number, whether a message should be received at that time, and the appropriate text of the message. The application is capable of storing multiple outgoing messages. With a few clicks, text messages are sent to study participants who can reply directly to the message. Study staff can check the local phone for incoming messages. The SMSMessenger application uses an existing clinical trial database and is able to receive real-time updates. All communications between the application and server are encrypted, and phone numbers are stored in a secure database behind a firewall. No sensitive data are stored on the phone, as outgoing messages are sent through the application and not by messaging features on the phone itself. Messages are sent simultaneously to study participants, which reduces the burden on local study staff. Costs and setup are minimal. The only local requirements are an Android phone and data plan. CONCLUSION: The SMSMessenger technology could be modified to be applied anywhere in the world, in any language, script, or alphabet, and for many different purposes. The novel application of this existing low-cost technology can improve the usefulness of text messaging in advancing the goals of international clinical trials.

Clinic-Based Urinary Lipoarabinomannan as a Biomarker of Clinical Disease Severity and Mortality Among Antiretroviral Therapy-Naive Human Immunodeficiency Virus-Infected Adults in South Africa.

BACKGROUND: Urinary lipoarabinomannan (LAM) has limited sensitivity for diagnosing active human immunodeficiency virus (HIV)-associated tuberculosis (TB) disease, but LAM screening at HIV diagnosis might identify adults with more severe clinical disease or greater risk of mortality. METHODS: We enrolled antiretroviral therapy-naive HIV-infected adults from 4 clinics in Durban. Nurses performed urine LAM testing using a rapid assay (Determine TB LAM) graded from low (1+) to high (≥3+) intensity. Urine LAM results were not used to guide anti-TB therapy. We assessed TB-related symptoms and obtained sputum for mycobacterial smear and culture. Participants were observed for 12 months, and we used multivariable Cox proportional hazard models to determine hazard ratios for all-cause mortality. RESULTS: Among 726 HIV-infected adults with median CD4 of 205 cells/mm3 (interquartile range, 79-350 cells/mm3), 93 (13%) were LAM positive and 89 (12%) participants died during the follow-up period. In multivariable analyses, urine LAM-positive participants had a mortality hazard ratio (MHR) of 3.58 (95% confidence interval [CI], 2.20-5.81) for all-cause mortality. Among participants with mycobacterial-confirmed TB, urine LAM-positivity had a 2.91 (95% CI, 1.26-6.73) MHR for all participants and a 4.55 (95% CI, 1.71-12.1) MHR for participants with CD4 ≤100 cell/mm3. Participants with LAM-positive TB had significantly more clinical signs and symptoms of disease, compared with participants with LAM-negative TB disease. CONCLUSIONS: Among HIV-infected adults, urinary LAM-positive patients had more clinical disease severity and a 3-fold increase in 12-month mortality compared with those who were LAM negative.