The Female Global Scholars Program: A mixed-methods evaluation of a novel intervention to promote the retention and advancement of women in global health research.

Fewer than 25% of global health leadership positions worldwide are held by women, adversely impacting women's health and widening gendered health disparities. The Female Global Scholars (FGS) Program, established in 2018 at Weill Cornell Medicine, is a two-year hybrid training and peer-mentorship program that promotes the retention and advancement of early-career female investigators conducting health research in low- and middle-income countries (LMICs). The purpose of this study is to determine the impact of the FGS Program on individual career advancement, academic productivity, and research self-efficacy. This mixed-methods study followed an explanatory sequential design. Participants completed an electronic survey collecting information on demographics, academic milestones, and research skill competency. Survey data were descriptively analyzed using R (Version 1.4.1106). In-depth interviews explored perceptions of the impact of the FGS Program on career development. The authors independently reviewed and thematically analyzed de-identified transcripts using NVivo (Version 13). In June 2022, twelve participants completed the survey. The median age was 40 years; 90% carried an MD, PhD, or other post-graduate degree. Since joining the FGS Program, respondents achieved a combined total of eight awarded grants, five academic promotions, 12 oral scientific presentations and 35 first-author peer-reviewed publications. Thematic analysis identified four overarching themes: gaining confidence through mimicry; improved self-efficacy to address gendered challenges; real-world application of scientific and career development skills; and building multi-disciplinary communities in a protected female-only space. We demonstrate that this low-cost training and mentorship program successfully addresses critical barriers that impede women's advancement in global health research. Our data may inform the adaptation of this initiative across other academic institutions.

Same-day testing with initiation of antiretroviral therapy or tuberculosis treatment versus standard care for persons presenting with tuberculosis symptoms at HIV diagnosis: A randomized open-label trial from Haiti.

BACKGROUND: Same-day HIV testing and antiretroviral therapy (ART) initiation is being widely implemented. However, the optimal timing of ART among patients with tuberculosis (TB) symptoms is unknown. We hypothesized that same-day treatment (TB treatment for those diagnosed with TB; ART for those not diagnosed with TB) would be superior to standard care in this population. METHODS AND FINDINGS: We conducted an open-label trial among adults with TB symptoms at initial HIV diagnosis at GHESKIO in Haiti; participants were recruited and randomized on the same day. Participants were randomized in a 1:1 ratio to same-day treatment (same-day TB testing with same-day TB treatment if TB diagnosed; same-day ART if TB not diagnosed) versus standard care (initiating TB treatment within 7 days and delaying ART to day 7 if TB not diagnosed). In both groups, ART was initiated 2 weeks after TB treatment. The primary outcome was retention in care with 48-week HIV-1 RNA <200 copies/mL, with intention to treat (ITT) analysis. From November 6, 2017 to January 16, 2020, 500 participants were randomized (250/group); the final study visit occurred on March 1, 2021. Baseline TB was diagnosed in 40 (16.0%) in the standard and 48 (19.2%) in the same-day group; all initiated TB treatment. In the standard group, 245 (98.0%) initiated ART at median of 9 days; 6 (2.4%) died, 15 (6.0%) missed the 48-week visit, and 229 (91.6%) attended the 48-week visit. Among all who were randomized, 220 (88.0%) received 48-week HIV-1 RNA testing; 168 had <200 copies/mL (among randomized: 67.2%; among tested: 76.4%). In the same-day group, 249 (99.6%) initiated ART at median of 0 days; 9 (3.6%) died, 23 (9.2%) missed the 48-week visit, and 218 (87.2%) attended the 48-week visit. Among all who were randomized, 211 (84.4%) received 48-week HIV-1 RNA; 152 had <200 copies/mL (among randomized: 60.8%; among tested: 72.0%). There was no difference between groups in the primary outcome (60.8% versus 67.2%; risk difference: -0.06; 95% CI [-0.15, 0.02]; p = 0.14). Two new grade 3 or 4 events were reported per group; none were judged to be related to the intervention. The main limitation of this study is that it was conducted at a single urban clinic, and the generalizability to other settings is uncertain. CONCLUSIONS: In patients with TB symptoms at HIV diagnosis, we found that same-day treatment was not associated with superior retention and viral suppression. In this study, a short delay in ART initiation did not appear to compromise outcomes. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov NCT03154320.

"Mobilizing our leaders": A multi-country qualitative study to increase the representation of women in global health leadership.

INTRODUCTION: Women play an essential role in health care delivery, and it is vital that they have equal representation in health leadership for equity, innovation, and the strengthening of health systems globally. Yet women remain vastly underrepresented in global health leadership positions, providing a clear example of the deeply rooted power imbalances that are central to the calls to decolonize global health. We conducted a multi-country study in Haiti, Tanzania, India, and the USA to examine gender-based challenges to career advancement for women in the global health workforce. Quantitative data on the type and prevalence of gender-based challenges has been previously reported. In this study, we analyze qualitative data collected through focus group discussions and in-depth interviews to understand women's experiences of gender-based obstacles to career advancement, their perceptions of underlying drivers, and perspectives on effective solutions. Guided by an adaptation of the Social Action Theory, we conducted focus group discussions and in-depth interviews with women at 4 major academic centers for clinical care and research in Haiti, India, Tanzania, and the United States. In total, 85 women participated in focus groups and 15 also participated in in-depth interviews. Discussions and interviews were conducted in the local language, by an experienced local facilitator unaffiliated with the participating institution, between 2017 and 2018. Discussions were recorded, transcribed, and translated. Data were analyzed by interpretive phenomenological methods for emergent themes. Three transcendent themes on gender-based challenges were identified: 1) cultural power imbalance, referring to the prevailing norms and engrained assumptions that women are less capable than men and that women's primary responsibility should be to their families; 2) institutional power imbalance, referring to the systematic gender bias upheld by existing leadership and power structures, and ranging from exclusion from career development opportunities to sexual harassment and assault; and 3) restricted agency, referring to women's limited ability to change their circumstances because of unequal cultural and institutional structures. Participants also described local, actionable solutions to address these barriers. These included: 1) formal reporting systems for sexual harassment and assault; 2) peer support and mentorship; and 3) accessible leadership training and mandatory gender equity training. Participants proposed feasible strategies to address gender-based challenges that could improve women's retention in health careers and foster their rise to leadership. Increasing the representation of women in global health leadership positions responds directly to efforts to decolonize global health and is integral to strengthening health systems and improving health outcomes for women and children worldwide.

Models of lifelong care for children and adolescents with chronic conditions in low-income and middle-income countries: a scoping review.

Globally, non-communicable diseases (NCDs) or chronic conditions account for one-third of disability-adjusted life-years among children and adolescents under the age of 20. Health systems must adapt to respond to the growing burden of NCDs among children and adolescents who are more likely to be marginalised from healthcare access and are at higher risk for poor outcomes. We undertook a review of recent literature on existing models of chronic lifelong care for children and adolescents in low-income and middle-income countries with a variety of NCDs and chronic conditions to summarise common care components, service delivery approaches, resources invested and health outcomes.

Novel, Low-Cost Intervention to Promote Women's Advancement in Global Health Research.

PROBLEM: Women comprise 7 out of every 10 health care workers globally yet are significantly underrepresented in leadership positions. The COVID-19 pandemic has exacerbated underlying gender disparities, placing additional burdens on many female global health professionals. APPROACH: The authors describe the development of a novel, low-cost pilot program-the Female Global Scholars Program (Weill Cornell Medicine)-established in April 2018 to promote the advancement of female global health research professionals and prepare them for leadership positions in this field. Using a logic model, the program was informed by discussion with peers at scientific symposia, qualitative research examining the barriers women experience in global health, discussions with experts in the fields of global health and medical education, and a literature review of other initiatives focused on fostering female advancement. The program provides opportunities to learn leadership skills and peer mentoring to female junior investigators in global health research over the course of 2 years through attendance of a symposium and skill-building workshop, skill-building webinars, and the building of a peer mentor group. OUTCOMES: The inaugural cohort of the Female Global Scholars Program (April 2018-March 2020) included 10 female global health researchers from 6 countries (Haiti, India, Kenya, Tanzania, Uganda, and the United States) across 3 continents. By the end of year 1, 6 participants received academic promotions. Additionally, the inaugural 10 scholars collectively presented at 11 international conferences and submitted 22 abstracts and 19 manuscripts. NEXT STEPS: The authors hope to provide additional support and guidance to scholars as they become leaders of their own versions of this program at their home sites and plan to expand the faculty group to further lessen the time burden, while enabling the program to provide additional research mentorship to scholars.

Point-of-care viral load testing among adolescents and young adults living with HIV in Haiti: a randomized control trial.

HIV viral load (VL) monitoring can reinforce antiretroviral therapy (ART) adherence. Standard VL testing requires high laboratory capacity and coordination between clinic and laboratory which can delay results. A randomized trial comparing point-of-care (POC) VL testing to standard VL testing among 150 adolescents and young adults, ages 10-24 years, living with HIV in Haiti determined if POC VL testing could return faster results and improve ART adherence and viral suppression. Participants received a POC VL test with same-day result (POC arm) or a standard VL test with result given 1 month later (SOC arm). POC arm participants were more likely to receive a test result within 6 weeks than SOC arm participants (94.7% vs. 80.1%; p1000 copies/ml and low self-reported ART adherence was stronger in the POC arm (OR: 6.57; 95%CI: 2.12-25.21) than the SOC arm (OR: 2.62; 95%CI: 0.97-7.44) suggesting more accurate self-report in the POC arm. POC VL testing was effectively implemented in this low-resource setting with faster results and is a pragmatic intervention that may enable clinicians to identify those with high VL to provide enhanced counseling or regimen changes sooner.Trial registration: ClinicalTrials.gov identifier: NCT03288246.

Preferences for family planning education among men and women in rural, highly religious Tanzanian communities: a discrete choice experiment.

Unmet need for family planning (FP) remains prevalent worldwide. In Tanzania, 21.7% of women desire to delay pregnancy, but do not use modern contraception despite its free availability at local clinics. Our prior data suggest that this is related to complex gender and religious dynamics in rural communities. To understand how education about FP could be improved, we developed a discrete choice experiment (DCE) to rank preferences of six attributes of FP education. Results were stratified by gender. Sixty-eight women and 76 men completed interview-assisted DCEs. Participants significantly preferred education by a clinician (men = 0.62, p < .001; women = 0.38, p < .001) and education in mixed-gender groups (men = 0.55, p < .001; women = 0.26, p < .001). Women also significantly preferred education by a religious leader (0.26, p = .012), in a clinic versus church, mosque, or community centre (0.31, p = .002), and by a female educator (0.12, p = .019). Men significantly preferred a male educator (0.17, p = .015), whom they had never met (0.25, p < .001), and educating married and unmarried people separately (0.22, p = .002). Qualitative data indicate women who had not previously used contraception preferred education led by a religious leader in a church or mosque. FP education tailored to these preferences may reach a broader audience, dispel misconceptions about FP and ultimately decrease unmet need.

Point-of-care viral load testing among adolescents and youth living with HIV in Haiti: a protocol for a randomised trial to evaluate implementation and effect.

INTRODUCTION: Adolescents living with HIV have poor antiretroviral therapy (ART) adherence and viral suppression outcomes. Viral load (VL) monitoring could reinforce adherence but standard VL testing requires strong laboratory capacity often only available in large central laboratories. Thus, coordinated transport of samples and results between the clinic and laboratory is required, presenting opportunities for delayed or misplaced results. Newly available point-of-care (POC) VL testing systems return test results the same day and could simplify VL monitoring so that adolescents receive test results faster which could strengthen adherence counselling and improve ART adherence and viral suppression. METHODS AND ANALYSIS: This non-blinded randomised clinical trial is designed to evaluate the implementation and effectiveness of POC VL testing compared with standard laboratory-based VL testing among adolescents and youth living with HIV in Haiti. A total of 150 participants ages 10-24 who have been on ART for >6 months are randomised 1:1 to intervention or standard arms. Intervention arm participants receive a POC VL test (Cepheid Xpert HIV-1 Viral Load system) with same-day result and immediate ART adherence counselling. Standard care participants receive a laboratory-based VL test (Abbott m2000sp/m2000rt) with the result available 1 month later, at which time they receive ART adherence counselling. VL testing is repeated 6 months later for both arms. The primary objective is to describe the implementation of POC VL testing compared with standard laboratory-based VL testing. The secondary objective is to evaluate the effect of POC VL testing on VL suppression at 6 months and participant comprehension of the correlation between VL and ART adherence. ETHICS AND DISSEMINATION: This study is approved by GHESKIO, Weill Cornell Medicine and Columbia University ethics committees. This trial will provide critical data to understand if and how POC VL testing may impact adolescent ART adherence and viral suppression. If effective, POC VL testing could routinely supplement standard laboratory-based VL testing among high-risk populations living with HIV. TRIAL REGISTRATION NUMBER: NCT03288246.

Interventions to Improve Antiretroviral Therapy Adherence Among Adolescents and Youth in Low- and Middle-Income Countries: A Systematic Review 2015-2019.

Adolescents and youth living with HIV have poorer antiretroviral treatment (ART) adherence and viral suppression outcomes than all other age groups. Effective interventions promoting adherence are urgently needed. We reviewed and synthesized recent literature on interventions to improve ART adherence among this vulnerable population. We focus on studies conducted in low- and middle-income countries (LMIC) where the adolescent and youth HIV burden is greatest. Articles published between September 2015 and January 2019 were identified through PubMed. Inclusion criteria were: [1] included participants ages 10-24 years; [2] assessed the efficacy of an intervention to improve ART adherence; [3] reported an ART adherence measurement or viral load; [4] conducted in a LMIC. Articles were reviewed for study population characteristics, intervention type, study design, outcomes measured, and intervention effect. Strength of each study's evidence was evaluated according to an adapted World Health Organization GRADE system. Articles meeting all inclusion criteria except being conducted in an LMIC were reviewed for results and potential transportability to a LMIC setting. Of 108 articles identified, 7 met criteria for inclusion. Three evaluated patient-level interventions and four evaluated health services interventions. Of the patient-level interventions, two were experimental designs and one was a retrospective cohort study. None of these interventions improved ART adherence or viral suppression. Of the four health services interventions, two targeted stable patients and reduced the amount of time spent in the clinic or grouped patients together for bi-monthly meetings, and two targeted patients newly diagnosed with HIV or not yet deemed clinically stable and augmented clinical care with home-based case-management. The two studies targeting stable patients used retrospective cohort designs and found that adolescents and youth were less likely to maintain viral suppression than children or adults. The two studies targeting patients not yet deemed clinically stable included one experimental and one retrospective cohort design and showed improved ART adherence and viral suppression outcomes. ART adherence and viral suppression outcomes remain a major challenge among adolescents and youth. Intensive home-based case management models of care hold promise for improving outcomes in this population and warrant further research.

Youth-friendly services and differentiated models of care are needed to improve outcomes for young people living with HIV.

PURPOSE OF REVIEW: Outcomes among young people living with HIV (YPLWH) remain disturbingly poor. We summarize recent research on youth-friendly services (YFS) and adolescent-specific differentiated care models, which may improve outcomes across the HIV care continuum for this vulnerable population. We further emphasize unique complexities that characterize the transition from childhood through adolescence to adulthood which must be considered when caring for YPLWH. RECENT FINDINGS: Studies suggest that YFS may improve outcomes in some but not all steps of the HIV care continuum. However, generalizability is compromised by the limited numbers of studies, frequent use of nonequivalent comparison groups, small sample sizes and/or short follow-up. Reproducibility and scale-up are further hindered by lack of insufficient details on operational aspects of YFS, an effective minimum package of YFS and contextual factors that may facilitate adoption of YFS. Differentiated models of care for YPLWH are in very early stages of development with positive preliminary outcomes, but most pilot models focus only on stable patients on antiretroviral therapy. SUMMARY: YFS and adolescent-specific differentiated models of care are needed to improve health outcomes among YPLWH, but scale-up should be guided by rigorous research and address the unique complexities that characterize the vulnerable period of adolescence.

Live with the Disease Like You Used to Before You Knew You Were Infected: A Qualitative Study Among 10-Year Survivors Living with HIV in Haiti.

In 2003, the Haitian Study Group on Kaposi's Sarcoma and Opportunistic Infections (GHESKIO), a nonprofit organization, began administering antiretroviral therapy (ART) to its patients. This practice transformed HIV from a fatal disease to a more manageable chronic condition. However, relatively few studies focus on the experiences of survivors. This study provided a unique opportunity to interview patients who survived at least 10 years after being treated with ART at GHESKIO. The goal of the study was to elicit from patients their perspectives on what enabled them to survive with AIDS. Grounded Theory, a qualitative research method was used to guide data collection, coding, and analysis. Individual interviews were conducted, audio-taped, transcribed and analyzed in Creole, and translated into English. Data saturation was reached at 25 participants. Of which, 64% were women, the mean age was 49, range of 43-55 years, 24% were married, 44% had not completed elementary school, and 72% had no income, the remaining participants had incomes ranging from $1000 to $5000 annually. Qualitative analysis resulted in 681 codes, which were grouped into six categories: being spiritually grounded, having supportive interactions with providers, caring for children, setting personal goals, persevering and living life as usual, and maintaining strict medication adherence practices. The overarching theory was that having a reason to live despite one's circumstances and living life as usual enabled one to survive. Having a strong spiritual foundation coupled with supportive family and providers motivated participants to live and adhere to their ART. As the number of patients who are living longer with HIV in Haiti increases, results from this study will be important in helping tailor interventions that enhance their overall quality of life.

Community-Based HIV and Health Testing for High-Risk Adolescents and Youth.

Adolescents account for 40% of new HIV infections, and HIV testing strategies to increase uptake of testing are needed. A community-based adolescent and youth HIV and health testing campaign was conducted in seven slum neighborhoods of Port-au-Prince, Haiti, from December 2014 to September 2015. Community health workers provided community sensitization and recruited 10- to 24-year-olds to test for HIV, syphilis, gonorrhea/chlamydia, and to screen for tuberculosis (TB) and pregnancy. HIV-infected individuals were escorted to the GHESKIO HIV clinic for same-day enrollment in care. Among 3425 individuals eligible for testing, 3348 (98%) accepted an HIV test. HIV prevalence was 2.65% (n = 89). Median age was 19 [interquartile range (IQR) 17-20]; 73% were female. HIV prevalence was 0.6-7.4% across slum neighborhoods. All HIV-infected individuals enrolled in care the same day as testing; median CD4 was 529 cells/µL [IQR 363-761]. Syphilis prevalence was 2.60% (65/2536) and gonorrhea/chlamydia prevalence was 6.25% (96/1536). Among 168 (5%) individuals who reported TB symptoms, 7.7% (13/168) had microbiologically confirmed disease. One hundred twenty-nine females (5% of all females) were pregnant. This community-based testing campaign identified an adolescent and youth population with an HIV prevalence six times higher than the estimated national adolescent HIV prevalence (0.4%) in Haiti, including perinatally infected adolescents. This type of community-based campaign for HIV testing within a package of services can serve as a model for other resource-poor settings to identify high-risk adolescents and youth, and curb the global HIV epidemic among adolescents.

Impact of a youth-friendly HIV clinic: 10 years of adolescent outcomes in Port-au-Prince, Haiti.

INTRODUCTION: Adolescents account for over 40% of new HIV infections in Haiti. This analysis compares outcomes among HIV-positive adolescents before and after implementation of an adolescent HIV clinic in Port-au-Prince, Haiti. METHODS: We conducted a cohort study using programmatic data among HIV-positive adolescents aged 13 to 19. Data from 41,218 adolescents who were HIV tested from January 2003 to December 2012 were included. Outcomes across the HIV care cascade were assessed before and after implementation of an adolescent clinic (2009), including HIV testing, enrolment in care, assessment for antiretroviral therapy (ART) eligibility, ART initiation and 12-month retention. Pre-ART outcomes were assessed 12 months after HIV testing. Factors associated with pre-ART and ART attrition were identified through multivariable competing risk and Cox proportional hazards regression modelling. RESULTS: Cumulatively, 1672 (4.1%) adolescents tested HIV positive (80% female, median age 16 years). Retention by cascade step comparing pre- and post-clinic included the following: 86% versus 87% of patients enrolled in care, 61% versus 79% were assessed for ART eligibility, 85% versus 92% initiated ART and 68% versus 66% were retained 12 months after ART initiation. Pre-ART attrition decreased from 61% pre-clinic to 50% post-clinic (p<0.001). Pre-ART attrition was associated with being female (sub-distributional hazard ratio (sHR): 1.59; CI: 1.31-1.93), syphilis diagnosis (sHR: 1.47; CI: 1.16-1.85) and slum residence (sHR: 0.84; CI: 0.72-0.97). ART attrition was associated with syphilis diagnosis (hazard ratio (HR): 2.23; CI: 1.35-3.68) and CD4 <50 cells/µL (HR: 1.88; CI: 1.15-3.06). CONCLUSIONS: Implementation of a youth-friendly adolescent clinic improved retention in HIV care among adolescents, particularly in the assessment of ART eligibility and ART initiation. Additional interventions are needed to improve retention among pre-ART patients and support long-term retention among ART patients.

Increasing women in leadership in global health.

Globally, women experience a disproportionate burden of disease and death due to inequities in access to basic health care, nutrition, and education. In the face of this disparity, it is striking that leadership in the field of global health is highly skewed towards men and that global health organizations neglect the issue of gender equality in their own leadership. Randomized trials demonstrate that women in leadership positions in governmental organizations implement different policies than men and that these policies are more supportive of women and children. Other studies show that proactive interventions to increase the proportion of women in leadership positions within businesses or government can be successful. Therefore, the authors assert that increasing female leadership in global health is both feasible and a fundamental step towards addressing the problem of women's health. In this Perspective, the authors contrast the high proportion of young female trainees who are interested in academic global health early in their careers with the low numbers of women successfully rising to global health leadership roles. The authors subsequently explore reasons for female attrition from the field of global health and offer practical strategies for closing the gender gap in global health leadership. The authors propose solutions aimed to promote female leaders from both resource-wealthy and resource-poor countries, including leadership training grants, mentorship from female leaders in global professions, strengthening health education in resource-poor countries, research-enabling grants, and altering institutional policies to support women choosing a global health career path.