Experiences of adolescents and youth with HIV testing and linkage to care through the Red Carpet Program (RCP) in Kenya.

Adolescents and youth living with HIV (AYLHIV) experience worse health outcomes compared to adults. We aimed to understand the experiences of AYLHIV in care in the youth-focused Red-Carpet program in Kenya to assess the quality of service provision and identify programmatic areas for optimization. We conducted focus group discussions among 39 AYLHIV (15-24 years) and structured analysis into four thematic areas. Within the HIV testing theme, participants cited fear of positive results, confidentiality and stigma concerns, and suggested engaging the community and youth in HIV testing opportunities. Within the HIV treatment adherence theme, participants cited forgetfulness, stigma, adverse side effects, lack of family support, and treatment illiteracy as barriers to adherence. Most participants reported positive experiences with healthcare providers and peer support. In terms of the HIV status disclosure theme, AYLHIV cited concerns about their future capacity to conceive children and start families and discussed challenges with understanding HIV health implications and sharing their status with friends and partners. Youth voices informing service implementation are essential in strengthening our capacity to optimize the support for AYLHIV within the community, at schools and healthcare facilities.

Clinical outcomes among adolescents living with HIV in Kenya following initiation on antiretroviral treatment.

In Kenya, HIV/AIDS remains a leading cause of morbidity and mortality among adolescents living with HIV (ALHIV). Our study evaluated associations between demographic and healthcare factors and HIV treatment outcomes among ALHIV in care in Kenya. This retrospective cohort study evaluated the clinical outcomes of newly diagnosed ALHIV enrolled in HIV care during January 2017-June 2018 at 32 healthcare facilities in Homabay and Kakamega Counties. Demographic and clinical data were abstracted from patient clinical records and registers during the follow up study period January 2017-through May 2019. ALHIV were stratified by age (10-14 versus 15-19 years). Categorical variables were summarized using descriptive statistics; continuous variables were analyzed using mean values. The latest available treatment and virological outcomes for ALHIV were assessed. 330 ALHIV were included in the study (mean age 15.9 years; 81.8% female, 63.0% receiving HIV care at lower-level healthcare facilities). Most (93.2%) were initiated on ART within 14 days of diagnosis; 91.4% initiated EFV-based regimens. Of those on ART, only 44.6% were active on care at the end of the study period. Of those eligible for viral load testing, 83.9% were tested with 84.4% viral suppression rate. Retention in care was higher at higher-level facilities (67.5%) compared to lower-level facilities (28.6%). Factors associated with higher retention in care were school attendance (aRR = 1.453), receipt of disclosure support (aRR = 13.315), and receiving care at a high-level health facility (aRR = 0.751). Factors associated with viral suppression included older age (15-19 years) (aRR = 1.249) and pre-ART clinical WHO stage I/II (RR = .668). Viral suppression was higher among older ALHIV. Studies are needed to evaluate effective interventions to improve outcomes among ALHIV in Kenya.

Supporting adolescents living with HIV within boarding schools in Kenya.

Adolescents and youth living with HIV (AYLHIV) are a uniquely vulnerable population facing challenges around adherence, disclosure of HIV status and stigma. Providing school-based support for AYLHIV offers an opportunity to optimize their health and wellbeing. The purpose of this study was to evaluate the feasibility of school-based supportive interventions for AYLHIV in Kenya. From 2016-2019, with funding from ViiV Healthcare, the Elizabeth Glaser Pediatric AIDS Foundation implemented the innovative Red Carpet Program (RCP) for AYLHIV in participating public healthcare facilities and boarding schools in Homa Bay and Turkana Counties in Kenya. In this analysis, we report the implementation of the school-based interventions for AYLHIV in schools, which included: a) capacity building for overall in-school HIV, stigma and sexual and reproductive health education; b) HIV care and treatment support; c) bi-directional linkages with healthcare facilities; and d) psychosocial support (PSS). Overall, 561 school staff and 476 school adolescent health advocates received training to facilitate supportive environments for AYLHIV and school-wide education on HIV, stigma, and sexual and reproductive health. All 87 boarding schools inter-linked to 66 regional healthcare facilities to support care and treatment of AYLHIV. Across all RCP schools, 546 AYLHIV had their HIV status disclosed to school staff and received supportive care within schools, including treatment literacy and adherence counselling, confidential storage and access to HIV medications. School-based interventions to optimize care and treatment support for AYLHIV are feasible and contribute to advancing sexual and reproductive health within schools.

The costs of diabetes treatment in low- and middle-income countries: a systematic review.

INTRODUCTION: The rising burden of diabetes in low- and middle-income countries may cause financial strain on individuals and health systems. This paper presents a systematic review of direct medical costs for diabetes (types 1 and 2) in low- and middle-income countries. METHODS: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, databases (PubMed, International Bibliography of Social Science, EconLit) were searched for publications reporting direct medical costs of type 1 and 2 diabetes. Data were extracted from all peer-reviewed papers meeting inclusion criteria, and were standardised into per-patient-visit, per-patient-year and/or per-complication-case costs (2016 US$). RESULTS: The search yielded 584 abstracts, and 52 publications were included in the analysis. Most articles were from Asia and Latin America, and most focused on type 2 diabetes. Per-visit outpatient costs ranged from under $5 to over $40 (median: $7); annual inpatient costs ranged from approximately $10 to over $1000 (median: $290); annual laboratory costs ranged from under $5 to over $100 (median: $25); and annual medication costs ranged from $15 to over $500 (median: $177), with particularly wide variation found for insulin. Care for complications was generally high-cost, but varied widely across countries and complication types. CONCLUSION: This review identified substantial variation in diabetes treatment costs; some heterogeneity could be mitigated through improved methods for collecting, analysing and reporting data. Diabetes is a costly disease to manage in low- and middle-income countriesand should be a priority for the global health community seeking to achieve Universal Health Coverage.

A systematic review of the use of adolescent mystery clients in assessing the adolescent friendliness of health services in high, middle, and low-income countries.

BACKGROUND: Mystery client methodology is a form of participatory research that provides a unique opportunity to monitor and evaluate the performance of health care providers or health facilities from the perspective of the service user. However, there are no systematic reviews that analyse the use of mystery clients in adolescent sexual and reproductive health (ASRH) research and monitoring and evaluation of programmes. OBJECTIVE: To assess the use of adolescent mystery clients in examining health care provider and facility performance in providing ASRH services in high, middle, and low-income countries. METHODS: We carried out a systematic review of published journal articles and reports from the grey literature on this topic from 2000 to 2017 (inclusive). Thirty research evaluations/studies were identified and included in the analysis. We identified common themes through thematic analysis. RESULTS: The findings reveal that researchers and evaluators used mystery client methodology to observe client-provider relationships, and to reduce observation bias, in government or private health facilities, NGOs, and pharmacies. The mystery clients in the evaluations/studies were young people who played varying roles; in most cases, they were trained for these roles. Most reported good experiences and friendly providers; however, some reported lack of privacy and confidentiality, lack of sufficient written/verbal information, and unfavourable experiences such as sexual harassment and judgmental comments. Female mystery clients were more likely than males to report unfavourable experiences. Generally, the methodology was considered useful in monitoring and evaluating the attitudes of health service providers and ASRH service provision. CONCLUSIONS: The research evaluations/studies in this review highlight the usefulness of mystery clients as a method to gain insight, from an adolescent perspective, on the quality of ASRH services for research and monitoring and evaluation of programmes.

A "Cap" on Medicaid: How Block Grants, Per Capita Caps, and Capped Allotments Might Fundamentally Change the Safety Net.

Changing the Medicaid program is a top priority for the Republican party. Common themes from GOP proposals include converting Medicaid from a jointly financed entitlement benefit to a form of capped federal financing. While proponents of this reform argue that it would provide greater flexibility and a more predictable budget for state governments, serious consequences would likely result for Medicaid enrollees and state governments. Under all three scenarios promoted by Republicans--block grants, capped allotments, and per capita caps­most states would face increased costs. For all three scenarios, the capped nature of the funding guarantees that the real value of funds would decrease in future years relative to what would be expected from growth under the current program. Although the federal government would undoubtedly realize savings from all three scenarios, the impact might lead states to reduce benefits and services, create waiting lists, impose cost-sharing on a traditionally low-income enrollee population, or impose other obstacles to coverage. Nationally, as many as 20.5 million Americans stand to lose coverage under the proposed Medicaid changes. In California, up to 6 million people could lose coverage if changes to the Medicaid program were coupled with the repeal of coverage for the expansion population.

Survival of metastatic gastric cancer: Significance of age, sex and race/ethnicity.

BACKGROUND: Despite the success of modern chemotherapy in the treatment of large bowel cancers, patients with metastatic gastric cancer continue to have a dismal outcome. Identifying predictive and prognostic markers is an important step to improving current treatment approaches and extending survival. METHODS: Extracting data from the US NCI's Surveillance, Epidemiology, and End Results (SEER) registries, we compared overall survival for patients with metastatic gastric cancer by gender, age, and ethnicity using Cox proportional hazards models. 13,840 patients (≥ 18 years) were identified from 1988-2004. Males and females were categorized by age grouping and ethnicity. RESULTS: 19% of Hispanic patients were diagnosed < 45 years of age as compared to 5.5% of Caucasians. Caucasian patients and men were more likely to be diagnosed with tumors in the gastric cardia (P<0.001). In our survival analysis, we found that women had a lower risk of dying as compared to men (P<0.001). Overall survival diminished with age (P<0.001). The median overall survival was 6 months in patients of ≤ 44 years old as compared to 3 months in patients 75 years and older. Gender differences in overall survival significantly varied by race and tumor grade/differentiation (P for interaction = 0.003 and 0.005, respectively). CONCLUSION: This is the largest study of metastatic gastric cancer patients from the SEER registry to show that age, gender, and tumor location are significant independent prognostic factors for overall survival in patients with metastatic gastric cancer.

Gender disparities in metastatic colorectal cancer survival.

PURPOSE: Previous studies have shown that estrogen prevents colon cancer in postmenopausal women, indicating a role in colorectal cancer carcinogenesis and tumor progression. We investigated the interactions between sex, age, ethnicity, and year of diagnosis on overall survival (OS) in patients with metastatic colorectal cancer (MCRC). EXPERIMENTAL DESIGN: We screened 52,882 patients with MCRC from 1988 to 2004, using the Surveillance Epidemiology and End Results registry. Age at diagnosis, sex, ethnicity, tumor location, year of diagnosis, OS, and cancer-specific survival were evaluated using Cox proportional hazards model. The models were adjusted for marital status, tumor site, tumor differentiation, and treatment with radiation and/or surgery. RESULTS: We observed that younger women (18-44 years old) with MCRC lived longer than younger men (17 months versus 14; P < 0.0001, log-rank test). In contrast, older women (55 years and older) had significantly worse OS than older men (7 months versus 9; P < 0.0001, log-rank test). In multivariate analysis, we found that gender discrepancies have widened in recent years; young women diagnosed after 2000 have improved cancer-specific survival, compared to men (hazard ratio, 0.778; 95% confidence interval, 0.669-0.904), but those diagnosed before 2000 benefit less (hazard ratio, 0.931; 95% confidence interval, 0.821-1.056). CONCLUSION: As one of the largest data sets analyzed to establish that younger women with MCRC survive longer than younger men, hormonal status not only seems to play an important role in the development and pathogenesis of colorectal cancer but also may be of prognostic significance. These data warrant further studies to determine the role of estrogen in colorectal cancer.