Screening and supporting through schools: Educational experiences and needs of adolescents living with HIV in a South African cohort

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Study Justification:
– Many adolescents living with HIV in high-prevalence settings are disconnected from care.
– Slow progressors, who survive without treatment, remain unidentified and disconnected from health systems.
– This study aims to identify educational markers for targeting HIV testing, counseling, and linkages to care.
– It also aims to identify essential areas of educational support for adolescents living with HIV.
Study Highlights:
– The study interviewed 1,063 adolescents living with HIV and 456 uninfected community control adolescents.
– It found that adolescents living with HIV accessed educational services at similar rates as other adolescents.
– However, living with HIV was associated with poorer attendance and educational delay.
– Adolescents with educational delay were more likely to be older, male, chronically sick, and have cognitive difficulties.
– Living with HIV was associated with poor physical, mental, and cognitive health, leading to worse educational experiences.
– Schools may provide an important opportunity to identify unreached adolescents living with HIV and link them into care.
Study Recommendations:
– Improve linkages to care for adolescents living with HIV, particularly in terms of educational support services.
– Focus on adolescents with poor attendance, frequent sickness, low mood, and slow learning.
– Use low attendance, frequent sickness, low mood, and slow learning as markers for identifying unreached adolescents living with HIV.
Key Role Players:
– South African national Departments of Health, Social Development, and Basic Education
– UNICEF
– UNAIDS
Cost Items for Planning Recommendations:
– Training for local research team
– Ethical approvals
– Data collection tools (tablets)
– Informed voluntary written consent process
– Healthcare and psychosocial services for at-risk adolescents
– Participation certificates and small packs of snacks and toiletries for all participants
– Translation and back-translation of measures
– Pre-piloting of data collection tools
– Collaboration with local health providers and stakeholders

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, as it presents quantitative data from a large sample size and includes statistical analyses. However, to improve the evidence, the abstract could provide more specific details about the methods used, such as the sampling strategy and data collection procedures.

Background: Many adolescents living with HIV remain disconnected from care, especially in high-prevalence settings. Slow progressors-adolescents infected perinatally who survive without access to lifesaving treatment-remain unidentified and disconnected from heath systems, especially in high-prevalence settings. This study examines differences in educational outcomes for ALHIV, in order to i) identify educational markers for targeting HIV testing, counselling and linkages to care, and ii) to identify essential foci of educational support for ALHIV. Methods: Quantitative interviews with N = 1063 adolescents living with HIV and N = 456 HIV-free community control adolescents (10-19 year olds) included educational experiences (enrolment, fee-free school, school feeding schemes, absenteeism, achievement), physical health, cognitive difficulties, mental health challenges (depression, stigma, and trauma), missing school to attend clinic appointments, and socio-demographic characteristics. Voluntary informed consent was obtained from adolescents and caregivers (when adolescent < 18 years old). Analyses included multivariate logistic regressions, controlling for socio-demographic covariates, and structural equation modelling using STATA15. Results: ALHIV reported accessing educational services (enrolment, free schools, school feeding schemes) at the same rates as other adolescents (94, 30, and 92% respectively), suggesting that school is a valuable site for identification. Living with HIV was associated with poorer attendance (aOR = 1.7 95%CI1.1-2.6) and educational delay (aOR1.7 95%CI1.3-2.2). Adolescents who reported educational delay were more likely to be older, male, chronically sick and report more cognitive difficulties. A path model with excellent model fit (RMSEA = 0.027, CFI 0.984, TLI 0.952) indicated that living with HIV was associated with a series of poor physical, mental and cognitive health issues which led to worse educational experiences. Conclusion: Schools may provide an important opportunity to identify unreached adolescents living with HIV and link them into care, focusing on adolescents with poor attendance, frequent sickness, low mood and slow learning. Key school-based markers for identifying unreached adolescents living with HIV may be low attendance, frequent sickness, low mood and slow learning. Improved linkages to care for adolescents living with HIV, in particular educational support services, are necessary to support scholastic achievement and long-term well-being, by helping them to cope with physical, emotional and cognitive difficulties.

This study interviewed 1519 adolescents comprising N = 1063 adolescents living with HIV and N = 456 un-infected community control adolescents (aged 10–19) in South Africa from 2014 to 2015. The study was designed in collaboration with the South African national Departments of Health, Social Development and Basic Education, UNICEF, and UNAIDS. Ethical approvals were obtained from Universities of Oxford (SSD/CUREC2/12–21), Cape Town (CSSR 2013/14), provincial department of Basic Education (04/04/2014) and Health (29/08/2013), and participating facilities. The study population included all adolescents ever initiated onto ART in all government-run health facilities (n = 53) in a municipal district of South Africa’s Eastern Cape Province. From 1176 patient files found, 90.3% (N = 1063) – were interviewed (4.1% refusals, 3.7% unreachable, 0.9% excluded due to severe cognitive delays). Included adolescents did not differ by age, gender and rural residence from those not reached [26]. Adolescents were interviewed in the communities where they lived (over 180 villages, wards, and neighbourhoods). Participating adolescents attended one of 415 schools in the district. To prevent potential stigmatisation of adolescents living with HIV, cohabiting or neighbouring adolescents who met age criteria were also interviewed (n = 456, 94.5% interviewed, 0.2% refusals, 5.3% were not traceable due to missing or incorrect contact details). HIV-status was categorised through a sequential confirmation process. First, HIV-positive status was verified through hand-searching of patient files and Tier. Net records in all health facilities where adolescents reported receiving care (n = 70 facilities), including two provincial hospitals, two regional hospitals, and five community health centres, responsible for initiating most patients on ART in the area [27]. If an adolescent ART file or record of having tested HIV-positive was located, participants were recoded as living with HIV. Second, adolescents without medical records of HIV status were screened using an evidence-based health symptoms and health history tool, developed to pick up suspected cases of HIV even among adolescents living with HIV who may be ‘slow progressors’ [28, 29]. Adolescents who did not meet the suspected HIV symptoms nor health history and had never tested HIV-positive based on medical records or self-reports, were interviewed and assigned HIV-negative status. The final sample included in this study included N = 1063 adolescents living with HIV and N = 456 HIV-uninfected peers. Interviews were conducted by a local team trained in sensitive and ethical research with HIV-affected children and adolescents. Questionnaires were administered on tablets to minimise missing data and improve data quality [30, 31]. Informed voluntary written consent was obtained from both adolescents and caregivers (when adolescents were  2 weeks in the previous term [35]. Educational delay was dichotomised using self-reported educational delay by ≥1 year behind school grade [35]. Chronic illness used adolescent report of symptomatic pulmonary TB, frequent ear infections, difficulties breathing, diarrhoea or nausea: all health issues shown to negatively affect school attendance and performance [36–38]. Missing school frequently to go to the clinic in the past year was documented through an item adapted from the PREPARE trial [39]. Cognitive difficulties were dichotomised as adolescent self-reported difficulties remembering to take their medicine – adapted from the WHO International Classification of Disability [40], caregiver-reported difficulty to concentrate at school and home, or attending a special school for children with cognitive disabilities (reported by either participant or caregiver). Answering ‘yes’ to either of these three types of difficulty was coded as reporting cognitive difficulties. Mental health challenges were measured as adolescent reporting at least one of three mental health states – depression, Post-Traumatic Stress Disorder (PTSD), or internalised stigma. Depression was measured as reporting above-median scores in the 10-item Child Development Inventory (past two weeks, Macdonald’s ω = 0.61), used extensively with children and adolescents in South Africa [41]. Past-month PTSD was measured with an abbreviated version of the Child PTSD Checklist [42], validated for use among adolescents in South Africa [43]. Internalised stigma used a scale adapted and validated with the study sample (α = 0.75) [26]. In addition, school-related externalising problems were measured by combining 2 school-related items from the Child Behaviour Checklist (CBCL) [44, 45], used in South Africa [46, 47] with 2 school-specific behaviour items from the Strengths and Difficulties Questionnaire (SDQ), validated in Xhosa speaking populations [48]. Socio-demographic variables included age, gender, rural/urban residence, informal/formal housing, and orphanhood (maternal and paternal), measured through items used in similar surveys with adolescents in South Africa [46, 49]. Poverty was measured as lacking at least one of eight top socially-perceived necessities for children and adolescents, confirmed by over 80% of the South African population in a nationally-representative survey [50]. Analyses took place in three stages using SPSS23 and STATA15: Hypothesised pathways between HIV status and educational experiences

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Based on the provided information, here are some potential innovations that could improve access to maternal health:

1. Mobile Clinics: Implementing mobile clinics that travel to remote areas or underserved communities can provide access to maternal health services for women who may not have easy access to healthcare facilities.

2. Telemedicine: Using telemedicine technology, healthcare providers can remotely provide prenatal care and consultations to pregnant women, reducing the need for them to travel long distances to receive care.

3. Community Health Workers: Training and deploying community health workers who can provide basic maternal health services, education, and support in their own communities can improve access to care for pregnant women.

4. Maternal Health Vouchers: Implementing a voucher system that provides pregnant women with financial assistance for maternal health services can help reduce financial barriers and improve access to care.

5. Health Education Programs: Developing and implementing health education programs that focus on maternal health can help increase awareness and knowledge among women and their families, leading to better access to care.

6. Transportation Support: Providing transportation support, such as vouchers or subsidies, to pregnant women who have difficulty accessing healthcare facilities can help ensure they can attend prenatal appointments and receive necessary care.

7. Maternal Health Hotlines: Establishing hotlines or helplines specifically for maternal health can provide pregnant women with a direct line to healthcare professionals who can answer questions, provide guidance, and connect them to necessary services.

8. Mobile Applications: Developing mobile applications that provide information, resources, and reminders for pregnant women can help improve access to maternal health information and support.

9. Collaborations with Schools: Partnering with schools to provide maternal health education and services can help reach adolescent girls and young women who may be at risk of early pregnancy and may not have access to traditional healthcare settings.

10. Public-Private Partnerships: Collaborating with private sector organizations and businesses to provide maternal health services and resources can help expand access and reach more women in need.

It’s important to note that these are just potential recommendations and would need to be further explored and evaluated for their feasibility and effectiveness in improving access to maternal health.
AI Innovations Description
The recommendation that can be developed into an innovation to improve access to maternal health is to implement a screening and support program through schools. This program would focus on identifying and providing necessary support to adolescents living with HIV who may be disconnected from healthcare systems. The study mentioned in the description found that schools can serve as valuable sites for identifying these adolescents.

The program would involve screening adolescents for HIV and other health issues, such as poor attendance, frequent sickness, low mood, and slow learning. Adolescents identified as living with HIV or in need of support would be linked to appropriate healthcare and psychosocial services. This would include providing educational support services to help them cope with physical, emotional, and cognitive difficulties.

By implementing this screening and support program through schools, more adolescents living with HIV can be identified and connected to the care they need. This would improve their access to maternal health services and support their scholastic achievement and long-term well-being.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Mobile Clinics: Implementing mobile clinics that can travel to remote areas and provide essential maternal health services such as prenatal care, vaccinations, and postnatal check-ups. This would ensure that women in underserved areas have access to necessary healthcare without having to travel long distances.

2. Telemedicine: Utilizing telemedicine technology to provide virtual consultations and follow-ups for pregnant women. This would be particularly beneficial for women who live in rural or isolated areas and have limited access to healthcare facilities.

3. Community Health Workers: Training and deploying community health workers who can provide education, support, and basic healthcare services to pregnant women in their communities. These workers can also serve as a bridge between the community and formal healthcare systems, ensuring that women receive appropriate care and referrals when needed.

4. Maternal Health Vouchers: Introducing a voucher system that provides financial assistance to pregnant women, enabling them to access essential maternal health services. This would help reduce financial barriers and ensure that women can afford the care they need.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific group of women who would benefit from improved access to maternal health services, such as pregnant women in underserved areas or low-income women.

2. Collect baseline data: Gather data on the current state of access to maternal health services in the target population, including factors such as distance to healthcare facilities, availability of services, and financial barriers.

3. Model the impact of each recommendation: Use mathematical modeling or simulation techniques to estimate the potential impact of each recommendation on improving access to maternal health. This could involve considering factors such as the number of women reached, the reduction in travel distance, or the increase in service utilization.

4. Assess the overall impact: Combine the results from each recommendation to determine the overall impact on access to maternal health. This could involve calculating metrics such as the percentage increase in service coverage or the reduction in maternal mortality rates.

5. Validate the results: Validate the simulation results by comparing them with real-world data or conducting pilot studies to assess the feasibility and effectiveness of implementing the recommendations.

6. Refine and iterate: Based on the simulation results and validation findings, refine the recommendations and methodology as needed. Iterate the process to further optimize the impact on improving access to maternal health.

It’s important to note that the specific methodology may vary depending on the available data, resources, and context of the target population.

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