Background The impact of public health policy to reduce the spread of COVID-19 on access to surgical care is poorly defined. We aim to quantify the surgical backlog during the COVID-19 pandemic in the Brazilian public health system and determine the relationship between state-level policy response and the degree of state-level delays in public surgical care. Methods Monthly estimates of surgical procedures performed per state from January 2016 to December 2020 were obtained from Brazil's Unified Health System Informatics Department. Forecasting models using historical surgical volume data before March 2020 (first reported COVID-19 case) were constructed to predict expected monthly operations from March through December 2020. Total, emergency, and elective surgical monthly backlogs were calculated by comparing reported volume to forecasted volume. Linear mixed effects models were used to model the relationship between public surgical delivery and two measures of health policy response: the COVID-19 Stringency Index (SI) and the Containment & Health Index (CHI) by state. Findings Between March and December 2020, the total surgical backlog included 1,119,433 (95% Confidence Interval 762,663–1,523,995) total operations, 161,321 (95%CI 37,468–395,478) emergent operations, and 928,758 (95%CI 675,202–1,208,769) elective operations. Increased SI and CHI scores were associated with reductions in emergent surgical delays but increases in elective surgical backlogs. The maximum government stringency (score = 100) reduced emergency delays to nearly zero but tripled the elective surgical backlog. Interpretation Strong health policy efforts to contain COVID-19 ensure minimal reductions in delivery of emergent surgery, but dramatically increase elective backlogs. Additional coordinated government efforts will be necessary to specifically address the increased elective backlogs that accompany stringent responses.

Background: Cognitive impairment is common in children and adolescents with human immunodeficiency virus (HIV). Brain magnetic resonance imaging (MRI) is a potentially useful tool to investigate the pathophysiology of HIV-associated cognitive impairment and may serve as a biomarker in future clinical trials. There are few published data on brain imaging in children with HIV in sub-Saharan Africa. Methods: Thirty-four perinatally infected subjects with HIV and age-matched HIV-exposed uninfected controls between the ages nine and 17 years were recruited from the Pediatric Center of Excellence in Lusaka, Zambia, as part of the HIV-associated Neurocognitive Disorders in Zambia study. Brain MRI sequences were acquired, and clinical and volumetric assessments were performed. Subjects underwent a comprehensive neuropsychologic battery, and cognitive impairment status was classified using a global deficit score approach. Regression models were used to evaluate relationships between MRI findings and cognitive function. Results: We identified cerebrovascular disease in seven of 34 subjects with HIV compared with zero of 17 controls (21% vs 0%, P ¼ 0.04). We also identified decreased total brain volumes (1036 vs 1162 cm 3 , P ¼ 0.03) and decreased cortical thickness in the right temporal lobes (3.12 vs 3.29 mm; P ¼ 0.01) and right fusiform gyri (3.10 vs 3.25 mm; P ¼ 0.02) of HIV-infected subjects with cognitive impairment. Conclusions: These findings support the hypothesis that brain volumes may be useful biomarkers for cognitive outcomes in children with HIV. Further studies are necessary to investigate mechanisms of cerebrovascular disease and volume loss in children with HIV.

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Background: Neurocysticercosis (NCC) is the most common parasitic infection of the brain and a leading cause of epilepsy in resource-limited settings. While NCC and Human Immunodeficiency Virus (HIV) co-infections have commonly been reported, there is little data on how they interact. As part of an observational study of HIV and cognition in Lusaka, Zambia, we identified a cluster of subjects with NCC. We hypothesized that neighborhood of residence may be an important factor driving clustering of NCC.Methods: 34 subjects with HIV and 13 subjects without HIV (ages 8-17) were enrolled in a prospective cohort study. All subjects had Magnetic Resonance Imaging (MRI) of the brain performed and were evaluated for NCC. Standardized interviews were conducted to identify potential risk factors for NCC. Quantitative Geographic Information Systems (QGIS) was utilized to investigate the relationship between neighborhood of residence, HIV, and NCC.Results: Three of 34 subjects with HIV (8.82%) and one of 13 controls were found to have NCC. Geographic cluster analysis demonstrated that all subjects with NCC were clustered in two adjacent neighborhoods (Chawama and Kanyama) with lower rates of piped water (C-22.8%, K-26.7%) and flush toilets (C-14.0%, K-14.0%) than surrounding neighborhoods.

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