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A growing body of literature demonstrates that healthcare providers use stigmatizing language when speaking and writing about patients. In April 2021, the 21st Century Cures Act compelled clinicians to make medical records open to patients. We believe that this is a unique moment to provide clinicians with guidance on how to avoid stigma and bias in our language as part of larger efforts to promote health equity. We performed an exhaustive scoping review of the gray and academic literature on stigmatizing medical language. We used thematic analysis and concept mapping to organize the findings into core principles for use in clinical practice. We compiled a list of terms to avoid and seven strategies to promote non-judgmental health record keeping: (1) use person-first language, (2) eliminate pejorative terms, (3) make communication inclusive, (4) avoid labels, (5) stop weaponizing quotes, (6) avoid blaming patients, and (7) abandon the practice of leading with social identifiers. While we offer guidance clinicians can use to promote equity through language on an individual level, health inequities are structural and demand simultaneous systems and policy change. By improving our language, we can disrupt the harmful narratives that allow health disparities to persist.

HIV remains a pressing global health problem, with 1.5 million new infections reported globally in 2020. HIV pre-exposure prophylaxis (PrEP) can lower the likelihood of HIV acquisition among populations at elevated risk, yet its global roll-out has been discouragingly slow. Psychosocial factors, such as co-occurring mental illness and substance use, are highly prevalent among populations likely to benefit from PrEP, and have been shown to undermine persistence and adherence. In this analysis, we review the high burden of mental health problems among PrEP candidates and contend that inattention to mental health stands to undermine efforts to implement PrEP on a global scale. We conclude that integration of mental health screening and treatment within PrEP scale-up efforts represents an important strategy for maximising PrEP effectiveness while addressing the high burden of mental illness among at-risk populations. As implementers seek to integrate mental health services within PrEP services, efforts to keep access to PrEP as low-threshold as possible should be maintained. Moreover, programmes should seek to implement mental health interventions that are sensitive to local resource constraints and seek to reduce intersecting stigmas associated with HIV and mental illness.

Worldwide, people with mental disorders are detained within the justice system at higher rates than the general population and often suffer human rights abuses. This review sought to understand the state of knowledge on the mental health of people detained in the justice system in Africa, including epidemiology, conditions of detention, and interventions. We included all primary research studies examining mental disorders or mental health policy related to detention within the justice system in Africa. 80 met inclusion criteria. 67% were prevalence studies and meta-analysis of these studies revealed pooled prevalence as follows: substance use 38% (95% CI 26–50%), mood disorders 22% (95% CI 16–28%), and psychotic disorders 33% (95% CI 28–37%). There were only three studies of interventions. Studies examined prisons (46%), forensic hospital settings (37%), youth institutions (13%), or the health system (4%). In 36% of studies, the majority of participants had not been convicted of a crime. Given the high heterogeneity in subpopulations identified in this review, future research should examine context and population-specific interventions for people with mental disorders. Electronic supplementary material The online version of this article (10.1186/s13033-019-0273-z) contains supplementary material, which is available to authorized users.

Background: Racial inequities for patients with heart failure (HF) have been widely documented. HF patients who receive cardiology care during a hospital admission have better outcomes. It is unknown whether there are differences in admission to a cardiology or general medicine service by race. This study examined the relationship between race and admission service, and its effect on 30-day readmission and mortality Methods: We performed a retrospective cohort study from September 2008 to November 2017 at a single large urban academic referral center of all patients self-referred to the emergency department and admitted to either the cardiology or general medicine service with a principal diagnosis of HF, who self-identified as white, black, or Latinx. We used multivariable generalized estimating equation models to assess the relationship between race and admission to the cardiology service. We used Cox regression to assess the association between race, admission service, and 30-day readmission and mortality. Results: Among 1967 unique patients (66.7% white, 23.6% black, and 9.7% Latinx), black and Latinx patients had lower rates of admission to the cardiology service than white patients (adjusted rate ratio, 0.91; 95% CI, 0.84–0.98, for black; adjusted rate ratio, 0.83; 95% CI, 0.72–0.97 for Latinx). Female sex and age >75 years were also independently associated with lower rates of admission to the cardiology service. Admission to the cardiology service was independently associated with decreased readmission within 30 days, independent of race. Conclusions: Black and Latinx patients were less likely to be admitted to cardiology for HF care. This inequity may, in part, drive racial inequities in HF outcomes.

Physicians as Border Guards Rules proposed by the Trump administration depend on physicians performing “exams” to spot immigrants who are sick enough to become reliant on the government for living ...

Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted for use in Africa. We selected, culturally adapted and tested the feasibility of a cognitive-behavioural intervention for adherence and for delivery in a clinic setting in Harare, Zimbabwe. The feasibility of the intervention was evaluated using a mixed-methods assessment, including ratings of provider fidelity of intervention delivery, and qualitative assessments of feasibility using individual semi-structured interviews with counsellors (n=4) and patients (n=15). The intervention was feasible and acceptable when administered to 42 patients and resulted in improved self-reported adherence in a subset of 15 patients who were followed up after 6months.

OBJECTIVE: HIV testing is the entry point to access HIV care. For HIV-infected children who survive infancy undiagnosed, diagnosis usually occurs on presentation to health care services. We investigated the effectiveness of routine opt-out HIV testing (ROOT) compared with conventional opt-in provider-initiated testing and counseling (PITC) for children attending primary care clinics. METHODS: After an evaluation of PITC services for children aged 6-15 years in 6 primary health care facilities in Harare, Zimbabwe, ROOT was introduced through a combination of interventions. The change in the proportion of eligible children offered and receiving HIV tests, reasons for not testing, and yield of HIV-positive diagnoses were compared between the 2 HIV testing strategies. Adjusted risk ratios for having an HIV test in the ROOT compared with the PITC period were calculated. RESULTS: There were 2831 and 7842 children eligible for HIV testing before and after the introduction of ROOT. The proportion of eligible children offered testing increased from 76% to 93% and test uptake improved from 71% to 95% in the ROOT compared with the PITC period. The yield of HIV diagnoses increased from 2.9% to 4.5%, and a child attending the clinics post intervention had a 1.99 increased adjusted risk (95% CI: 1.85 to 2.14) of receiving an HIV test in the ROOT period compared with the preintervention period. CONCLUSION: ROOT increased the proportion of children undergoing HIV testing, resulting in an overall increased yield of positive diagnoses, compared with PITC. ROOT provides an effective approach to reduce missed HIV diagnosis in this age group.

HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of one's HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight fifty eight HIV-positive adolescents (10–19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers. N = 128 (14.9%) of the total sample had ever had sex, while N = 109 (85.1%) of sexually active adolescents had boy/girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partner's status, and 35.5% had disclosed to their partners. For adolescents, knowing one's status was associated with safer sex (OR = 4.355, CI 1.085–17.474, p = .038). Neither knowing their partner's status, nor disclosing one's HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be ill-equipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex.

OBJECTIVE: To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings.METHODS: In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team.RESULTS: The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care.CONCLUSIONS: Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.

Summary There has been little external analysis of Zimbabwe's mental health system. We did a systems analysis to identify bottlenecks and opportunities for mental health service improvement in Zimbabwe and to generate cost-effective, policy-relevant solutions. We combined in-depth interviews with a range of key stakeholders in health and mental health, analysis of mental health laws and policies, and publicly available data about mental health. Five themes are key to mental health service delivery in Zimbabwe: policy and law; financing and resources; criminal justice; workforce, training, and research; and beliefs about mental illness. We identified human resources, rehabilitation facilities, psychotropic medication, and community mental health as funding priorities. Moreover, we found that researchers should prioritise measuring the economic impact of mental health and exploring substance use, forensic care, and mental health integration. Our study highlights forensic services as a central component of the mental health system, which has been a neglected concept. We also describe a tailored process for mental health systems that is transferable to other low-income settings and that garners political will, builds capacity, and raises the profile of mental health.

Introduction Few people with mental disorders in low and middle-income countries (LMICs) receive treatment, in part because mental disorders are highly stigmatized and do not enjoy priority and resources commensurate with their burden on society. Advocacy has been proposed as a means of building political will and community support for mental health and reducing stigma, but few studies have explored the practice and promise of advocacy in LMICs. Methods We conducted 30 semi-structured interviews with leaders in health and mental health in Zimbabwe to explore key stakeholder perceptions on the challenges and opportunities of the country’s mental health system. We coded the transcripts using the constant comparative method, informed by principles of grounded theory. Few interview questions directly concerned advocacy, yet in our analysis, advocacy emerged as a prominent, cross-cutting theme across participants and interview questions. Results Two thirds of the respondents discussed advocacy, often in depth, returning to the concept throughout the interview and emphasizing their belief in advocacy’s importance. Participants described six distinct components of advocacy: the advocates, to whom they advocate (“targets”), what they advocate for (“asks”), how advocates reach their targets (“access”), how they make their asks (“arguments”), and the results of their advocacy (“outcomes”). Discussion Despite their perception that mental health is widely misunderstood and under-appreciated in Zimbabwe, respondents expressed optimism that strategically speaking out can reduce stigma and increase access to care. Key issues included navigating hierarchies, empowering service users to advocate, and integrating mental health with other health initiatives. Understanding stakeholder perceptions sets the stage for targeted development of mental health advocacy in Zimbabwe and other LMICs.

In November 2017, following a military intervention, Robert Mugabe was forced to resign as president of Zimbabwe – where he had ruthlessly ruled since 1980. Mugabe’s regime was responsible for destroying the country’s excellent health system. I argue that this is a unique moment for health reform in Zimbabwe. This reform should focus on three areas: (1) repairing relationships with the international community by focusing on human rights and eliminating corruption, (2) strengthening the health workforce through retention strategies, training, and non-specialist providers, and (3) community engagement. The future of Zimbabwe’s health system is in limbo, and now is a unique opportunity to make positive change.

Objectives: WHO guidelines recommend disclosure to HIV-positive children by school age in order to improve antiretroviral therapy (ART) adherence. However, quantitative evidence remains limited for adolescents. This study examines associations between adolescent knowledge of HIV-positive status and ART-adherence in South Africa. Design: A cross-sectional study of the largest known community-traced sample of HIV-positive adolescents. Six hundred and eighty-four ART-initiated adolescents aged 10–19 years (52% female, 79% perinatally infected) were interviewed. Methods: In a low-resource health district, all adolescents who had ever initiated ART in a stratified sample of 39 health facilities were identified and traced to 150 communities [n = 1102, 351 excluded, 27 deceased, 40 (5.5%) refusals]. Quantitative interviews used standardized questionnaires and clinic records. Quantitative analyses used multivariate logistic regressions, and qualitative analyses used grounded theory for 18 months of interviews, focus groups and participant observations with 64 adolescents, caregivers and healthcare workers. Results: About 36% of adolescents reported past-week ART nonadherence, and 70% of adolescents knew their status. Adherence was associated with fewer opportunistic infection symptoms [odds ratio (OR) 0.55; 95% CI 0.40–0.76]. Adolescent knowledge of HIV-positive status was associated with higher adherence, independently of all cofactors (OR 2.18; 95% CI 1.47–3.24). Among perinatally infected adolescents who knew their status (n = 362/540), disclosure prior to age 12 was associated with higher adherence (OR 2.65; 95% CI 1.34–5.22). Qualitative findings suggested that disclosure was undertaken sensitively in clinical and family settings, but that adults lacked awareness about adolescent understandings of HIV status. Conclusion: Early and full disclosure is strongly associated with improved adherence amongst ART-initiated adolescents. Disclosure may be an essential tool in improving adolescent adherence and reducing mortality and onwards transmission.

Rashida Ferrand and colleagues combine quantitative and qualitative methods to investigate HIV prevalence among older children receiving primary care in Harare, Zimbabwe, and reasons why providers did not pursue testing. Please see later in the article for the Editors' Summary, Background There is a substantial burden of HIV infection among older children in sub-Saharan Africa, the majority of whom are diagnosed after presentation with advanced disease. We investigated the provision and uptake of provider-initiated HIV testing and counselling (PITC) among children in primary health care facilities, and explored health care worker (HCW) perspectives on providing HIV testing to children. Methods and Findings Children aged 6 to 15 y attending six primary care clinics in Harare, Zimbabwe, were offered PITC, with guardian consent and child assent. The reasons why testing did not occur in eligible children were recorded, and factors associated with HCWs offering and children/guardians refusing HIV testing were investigated using multivariable logistic regression. Semi-structured interviews were conducted with clinic nurses and counsellors to explore these factors. Among 2,831 eligible children, 2,151 (76%) were offered PITC, of whom 1,534 (54.2%) consented to HIV testing. The main reasons HCWs gave for not offering PITC were the perceived unsuitability of the accompanying guardian to provide consent for HIV testing on behalf of the child and lack of availability of staff or HIV testing kits. Children who were asymptomatic, older, or attending with a male or a younger guardian had significantly lower odds of being offered HIV testing. Male guardians were less likely to consent to their child being tested. 82 (5.3%) children tested HIV-positive, with 95% linking to care. Of the 940 guardians who tested with the child, 186 (19.8%) were HIV-positive. Conclusions The HIV prevalence among children tested was high, highlighting the need for PITC. For PITC to be successfully implemented, clear legislation about consent and guardianship needs to be developed, and structural issues addressed. HCWs require training on counselling children and guardians, particularly male guardians, who are less likely to engage with health care services. Increased awareness of the risk of HIV infection in asymptomatic older children is needed. Please see later in the article for the Editors' Summary, Editors' Summary Background Over 3 million children globally are estimated to be living with HIV (the virus that causes AIDS). While HIV infection is most commonly spread through unprotected sex with an infected person, most HIV infections among children are the result of mother-to-child HIV transmission during pregnancy, delivery, or breastfeeding. Mother-to-child transmission can be prevented by administering antiretroviral therapy to mothers with HIV during pregnancy, delivery, and breast feeding, and to their newborn babies. According to a report by the Joint United Nations Programme on HIV/AIDS published in 2012, 92% of pregnant women with HIV were living in sub-Saharan Africa and just under 60% were receiving antiretroviral therapy. Consequently, sub-Saharan Africa is the region where most children infected with HIV live. Why Was This Study Done? If an opportunity to prevent mother-to-child transmission around the time of birth is missed, diagnosis of HIV infection in a child or adolescent is likely to depend on HIV testing in health care facilities. Health care provider–initiated HIV testing and counselling (PITC) for children is important in areas where HIV infection is common because earlier diagnosis allows children to benefit from care that can prevent the development of advanced HIV disease. Even if a child or adolescent appears to be in good health, access to care and antiretroviral therapy provides a health benefit to the individual over the long term. The administration of HIV testing (and counselling) to children relies not only on health care workers (HCWs) offering HIV testing but also on parents or guardians consenting for a child to be tested. However, more than 30% of children in countries with severe HIV epidemics are AIDS orphans, and economic conditions in these countries cause many adults to migrate for work, leaving children under the care of extended families. This study aimed to investigate the reasons for acceptance and rejection of PITC in primary health care settings in Harare, Zimbabwe. By exploring HCW perspectives on providing HIV testing to children and adolescents, the study also sought to gain insight into factors that could be hindering implementation of testing procedures. What Did the Researchers Do and Find? The researchers identified all children aged 6 to 15 years old at six primary care clinics in Harare, who were offered HIV testing as part of routine care between 22 January and 31 May 2013. Study fieldworkers collected data on numbers of child attendances, numbers offered testing, numbers who underwent HIV testing, and reasons why HIV testing did not occur. During the study 2,831 children attending the health clinics were eligible for PITC, and just over half (1,534, 54.2%) underwent HIV testing. Eighty-two children tested HIV-positive, and nearly all of them received counselling, medication, and follow-up care. HCWs offered the test to around 75% of those eligible. The most frequent explanation given by HCWs for a diagnostic test not being offered was that the child was accompanied by a guardian not appropriate for providing consent (401 occasions, 59%); Other reasons given were a lack of available counsellors or test kits and counsellors refusing to conduct the test. The likelihood of being offered the test was lower for children not exhibiting symptoms (such as persistent skin problems), older children, or those attending with a male or a younger guardian. In addition, over 100 guardians or parents provided consent but left before the child could be tested. The researchers also conducted semi-structured interviews with 12 clinic nurses and counsellors (two from each clinic) to explore challenges to implementation of PITC. The researchers recorded the factors associated with testing not taking place, either when offered to eligible children or when HCWs declined to offer the test. The interviewees identified the frequent absence or unavailability of parents or legal guardians as an obstacle, and showed uncertainty or misconceptions around whether testing of the guardian was mandatory (versus recommended) and whether specifically a parent (if one was living) must provide consent. The interviews also revealed HCW concerns about the availability of adequate counselling and child services, and fears that a child might experience maltreatment if he or she tested positive. HCWs also noted long waiting times and test kits being out of stock as practical hindrances to testing. What Do These Findings Mean? Prevalence of HIV was high among the children tested, validating the need for PITC in sub-Saharan health care settings. Although 76% of eligible attendees were offered testing, the authors note that this is likely higher than in routine settings because the researchers were actively recording reasons for not offering testing and counselling, which may have encouraged heath care staff to offer PITC more often than usual. The researchers outline strategies that may improve PITC rates and testing acceptance for Zimbabwe and other sub-Saharan settings. These strategies include developing clear laws and guidance concerning guardianship and proxy consent when testing older children for HIV, training HCWs around these policies, strengthening legislation to address discrimination, and increasing public awareness about HIV infection in older children. Additional Information Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001649. This study is further discussed in a PLOS Medicine Perspective by Davies and Kalk The Joint United Nations Programme on HIV/AIDS publishes an annual report on the global AIDS epidemic, which provides information on progress towards eliminating new HIV infections The World Health Organization has more information on mother-to-child transmission of HIV The World Health Organization's website also has information about treatment for children living with HIV Personal stories about living with HIV/AIDS, including stories from young people infected with HIV, are available through Avert, through NAM/aidsmap, and through the charity website Healthtalkonline

Background: Kidney injury is a complication of Human Immunodeficiency Virus (HIV) infection. Albuminuria, ranging from microabuminuria to macroalbuminuria, is a marker of renal injury in other systemic illnesses and also an indicator of subclinical renal disease among HIV-seropositive individuals. Recent studies have shown that albuminuria and declining glomerular filtration rates are associated with faster progression to AIDS and mortality. Early detection of albuminuria may benefit from early treatment with highly active antiretroviral therapy (HAART) and drugs that delay progression to end-stage renal disease. There is paucity of studies on the burden of HIV-associated renal complications especially in Asian populations, along with the lack of local data on prevalence of albuminuria among Filipino HIV patients, hence this study. Methods&Materials: This is a cross-sectional study that determined the prevalence and relationship of albuminuria among 198 adultHIV-seropositivepatients seenat theSAGIPUnit of PGH.Urine samples were tested for albuminuria using standard urine dipstick while those with negative, trace and+1 results were further tested for microalbuminuria using urine Micral test. Data was analyzed using structural equation modeling (SEM) to identify relationships of albuminuria with HIV status and HAART use. Results: Albuminuria was present in 9.6% of respondents, of these, 63% were in the microalbuminuric range. Using SEM, albuminuria was inversely associated with HAART, as those patient not on HAART were likely to have albuminuria (p 1 year of HAART were less likely to develop albuminuria regardless of clinical stage (p=0.000). The duration of HAART had full mediation to this relationship. Conclusion: This study showed lower rates of albuminuria as well as microalbuminuria among Filipino HIV patients compared to those from the Middle East and Africa. The rate of microalbuminuria was actually comparable with the worldwide prevalence in the general population. This study showed that longer HAART use was related to decreased likelihood of having albuminuria. The authors recommend routine screening for microalbuminuria inHIV-seropositive patients to identify thosewhowill benefit from early intervention.

Background:HIV testing is the first step to linking people living with HIV to treatment.Treatment coverage in children disproportionately lags behind that in adults, with only 28% of infected children accessing antiretroviral therapy (ART). Provider-initiated counselling and testing (PITC) is recommended in settings with generalised epidemics. We investigated the extent to which this is implemented for children in routine healthcare in Zimbabwe. Methods & Materials: We implemented PITC at six primarycare clinics in Harare, Zimbabwe. Between January and August 2013, 132childrenaged6-15yearswho testedpositive through this intervention had a family and clinical history recorded and underwent a clinical examination, includingWHOStaging and CD4 count to investigate previously missed opportunities for diagnosis. Results: Median age was 11 (IQR 9-13) years and 50% were female. All children were vertically-infected and 5 (4%) had tested HIV-positive in the past but not linked to care. The median CD4 count was 322 ((IQR 190-544) cells/ l, and 76 (58%) were eligible for ART. 83 (63%) were orphans and 85 (65%) had experienced one or more changes in guardianship. More than half of children currently had a non-parent guardian (29 (22%) grandparents, 24 (18%) uncles/aunts; 9 (7%) siblings; 5(4%) other). Overall, 116 (88%) had a missed opportunity for earlier diagnosis: 76 (58%) of children had a parent or natural sibling who was already taking ART but the child had not been offeredHIV testing; 6 (5%) had been treated for tuberculosis; 38 (29%) had a past hospital admission; 88 (67%) had attended a primary care clinic in the past six months. Two-thirds of guardians had suspected that their child would test HIV-positive. Conclusion: PITC for children in healthcare facilities remains suboptimal. Opportunities to identify HIV-infected children are currently missed as family members of HIV-infected individuals are not offered testing. HIV infected children frequently experience changes in guardianship and loss of their parents, which may increase their vulnerability and further contribute to delayed diagnosis. Policy makers urgently need to develop child-focused HIV testing services and track family members of identified HIV positive individuals to address the treatment gap for children living with HIV.

Introduction & objectivesDue to the scale up of antiretroviral therapy, increasing numbers of HIV-infected children are living into adolescence. As these children grow and surpass the immediate threat of death, the issue of informing them of their HIV status arises. This study aimed to understand how perinatally-infected adolescents learn about their HIV-status as well as to examine their preferences for the disclosure process.MethodsIn-depth interviews were conducted with 31 (14 male, 17 female) perinatally-infected adolescents aged 16-20 at an HIV clinic in Harare, Zimbabwe, and focused on adolescents' experiences of disclosure. In addition, 15 (1 male, 14 female) healthcare workers participated in two focus groups that were centred on healthcare workers' practices surrounding disclosure in the clinic. Purposive sampling was used to recruit participants. A coding frame was developed and major themes were extracted using grounded theory methods.ResultsHealthcare workers encouraged caregivers to initiate disclosure in the home environment. However, many adolescents preferred disclosure to take place in the presence of healthcare workers at the clinic because it gave them access to accurate information as well as an environment that made test results seem more credible. Adolescents learned more specific information about living with an HIV-positive status and the meaning of that status from shared experiences among peers at the clinic.ConclusionsHIV-status disclosure to adolescents is distinct from disclosure to younger children and requires tailored, age-appropriate guidelines. Disclosure to this age group in a healthcare setting may help overcome some of the barriers associated with caregivers disclosing in the home environment and make the HIV status seem more credible to an adolescent. The study also highlights the value of peer support among adolescents, which could help reduce the burden of psychosocial care on caregivers and healthcare workers.

In The Lancet Psychiatry, Khameer Kidia and colleagues propose that carefully selected and trained adolescents living with HIV can effectively help the delivery of mental health care for other adolescents living with HIV. We concur, and want to bring attention to a National Institute of Child Health and Human Developmentfunded project in Kigali, Rwanda, where we are doing exactly what Kidia and colleagues recommend: trained HIV-positive Rwandan youths deliver a trauma-informed cognitive behavioural intervention to improve adherence to antiretroviral therapy in young people with HIV. Since 2004, Women’s Equity in Access to Care and Treatment (WEACTx) has provided integrated primary care to women, men, and children with HIV. Psychosocial services and support groups are an essential component of culturally sensitive quality care. HIV-positive youths attend support groups to develop social support and gain knowledge about HIV. Since 2010, adolescents aged 19 years and older have been trained as so-called peer parents to help counsellors in leading activities and discussions with younger youths. After observing successful engagement of peer parents and youths, we developed a youth-led group-based intervention to improve medication adherence in 14–21-year-olds at WE-ACTx and University Teaching Hospital of Kigali (CHUK) youth programmes. In January, 2013, we initiated a randomised controlled trial to assess a six-session youth-led intervention to increase antiretroviral therapy adherence compared with usual care. Working closely with Rwandan mental health providers and adolescents living with HIV, a US-based psychologist adapted an evidence-based intervention for the Rwandan context. The intervention addresses knowledge about HIV; safer sex practices; stigma; gender-based violence; trauma; cognitive behavioural strategies that promote learning connections between thoughts, feelings, and behaviours; and problemsolving skills to resolve adherence obstacles. Movement-based relaxation techniques are also practiced. 18 youth leaders from peer parent groups were selected from the WEACTx and CHUK youth programmes. Rwandan-trained psychologists with BA qualifications were recruited to supervise the youth leaders. The USA-based psychologist provided 14 days of training for the youth leaders, assisted by the psychologists, to teach the curriculum, practice the intervention strategies, review group dynamics and leadership skills, and receive feedback to improve their facilitation. Ongoing supervision is provided by a cascade approach, in which the US psychologist has weekly Skype calls with the psychologists who then supervise the youth leaders twice per week. In-person consultations with youth leaders and psychologists take place biannually. At study midpoint (April 4, 2015), 198 youths have completed baseline assessments, of whom 99 remain in usual treatment and 99 in intervention groups. After the 6-month and 12-month assessments, participants will attend a youth-led booster session and will be re-assessed at 18 months. Fidelity data collected by self-reports and observer reports for ten groups showed good observance to and delivery of the curriculum. Therefore, our experience supports the idea that adolescents living with HIV can eff ectively and with fi delity lead mental health interventions for HIV-infected youths. We are encouraged by the enthusiasm, competence, and confidence of the youth leaders during their training and their skill as intervention facilitators. We believe that adolescents living with HIV will have an important role in improving HIV care for themselves and other aff ected youths.

K. Kidia, D. Machando, T. Bere, P. Nymayaro, J. Magidson, K. Machpherson, R. Araya, C. O’Cleirigh, S. Safren, D. Chibanda, M. Abas; Icahn School of Medicine at Mount Sinai University of Zimbabwe College of Health Sciences, New York, NY/US, University of Zimbabwe, Harare, Zimbabwe, Icahn School of Medicine at Mount Sinai, Harare, Zimbabwe, Massachussets General Hospital, Boston, MA/US, King’s College London, Institute of Psychiatry, London, US, London School of Hygiene and Tropical Medicine, London, UK, Massachussets General Hospital, Boston, US, King’s College London, Institute of Psychiatry, London, UK

Additional file 1. Appendices S1â S11.

Additional file 1. Appendices S1â S11.