Mental health treatment to reduce HIV transmission risk behavior: a positive prevention model

Impact of mental health service use on the HIV care cascade among women

BACKGROUND

While the negative effects of mental health issues on HIV clinical outcomes have been well-documented, the impact of mental health treatment on the HIV care cascade is largely uncharacterized. The objective of this study was to describe the engagement of women with mental health conditions and symptoms, who reported using mental health services, across the HIV care cascade and to assess the relationship between mental health service use and HIV care steps.

METHODS

Longitudinal data were analysed from participants enrolled in the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS) (2013-2018) who had clinically significant depressive symptoms or reported a mental health diagnosis at baseline. Among this subset, four states of HIV care were defined at baseline, 18 months and 36 months: (1) unengaged in care (did not visit an HIV provider in the past year), (2) not on antiretroviral therapy (ART) (visited an HIV provider in the past year but did not report current ART use), (3) detectable (reported current ART use but a detectable viral load) and (4) optimal (reported current ART use and an undetectable viral load). Sankey diagrams were used to illustrate the engagement of women across the HIV care cascade over 3 years based on their self-reported use of mental health services at baseline. The association between mental health service use and care state at baseline was analysed using multinomial logistic regression models.

RESULTS

Of the 898 women in the cohort with significant depressive symptoms or mental health conditions at baseline, 3.8% (n = 34) were unengaged in care, 10.9% (n = 98) were not on ART, 12.4% (n = 111) were detectable and 72.9% (n = 655) were optimal. Over the 36 months, 51.0% of women transitioned between states at least once. When stratified by service use, women who reported use of mental health services at baseline had better engagement across the care cascade and had fewer transitions between states over the 3 years, 37.2% of which were to better states of care. The use of mental health services at baseline was also significantly associated with greater odds of engagement in the optimal state compared with not on ART (adjusted odds ratio [aOR]: 1.72, 95% confidence interval [CI]: 1.07-2.77). A similar but statistically insignificant association was found with the detectable care state (aOR: 1.67, 95% CI: 0.92-3.03).

CONCLUSIONS

Our findings demonstrate that linkage to mental health care has a positive impact on HIV care outcomes among women. Accessible mental health services may serve to improve both mental well-being and progression of these patients along the HIV care cascade, thereby achieving individual and public health goals.

Between a Rock and a Hard Place: "I Decided to Keep Quiet": A Qualitative Inquiry Into the Coping Experiences of Young People (15-24) Working at High-Risk Venues for HIV in Uganda

Employment linked with social venues has long been described as permissive environments for excessive drinking, disruptive/aggressive behaviors, and overt sexual behaviors, which are known risk factors for HIV. Yet, our understanding of the extent to which workers in such high-risk work settings cope with the various risks therein is still limited. This study explored the coping strategies employed by workers at social venues. We interviewed 47 workers at 22 social venues through small group discussions (15) and in-depth interviews (10) in 2021 in Rakai district, Uganda. All discussions were audiorecorded and transcribed verbatim before analysis. Data were analyzed using thematic content analysis. We found two main categories of coping strategies used by workers: acceptance of sexual risks and keeping safe. Acceptance of risks such as transactional sex was the most used strategy, hence highlighting negative coping. This calls for interventions for improving workers' coping efficiency and adjustment as well as interventions ameliorating the conditions underpinning increased risk of HIV at the venues.

Posttraumatic Stress Disorder Symptoms and Incarceration: The Impact on Sexual Risk-Taking, Sexually Transmitted Infections, and Depression Among Black Sexual Minority Men in HIV Prevention Trials Network (HPTN) 061

Black men and people belonging to sexual minority groups are disproportionately impacted by criminal legal involvement and sexually transmitted infections (STIs). Traumatic experiences are often associated with later criminal legal involvement, depression symptoms, sexual risk behavior, and STIs. Research on the joint influence of trauma and incarceration on STI risk among racial and/or sexual minority people is limited. This study tested the association between post-traumatic stress disorder (PTSD) symptoms and incarceration on sexual risk behavior and STI among Black sexual minority men, a population that may be at higher risk for contracting STIs. Using data from the HIV Prevention Trials Network 061 Study, a longitudinal study of adult Black sexual minority men in six U.S. cities (N = 855), we tested associations between past six-month incarceration and subsequent sexual risk behavior, STI, and depression symptoms, for those with and without pre-incarceration PTSD symptoms. PTSD symptoms were elevated among participants who reported Hispanic ethnicity, having sex with both men and women, and previous incarceration. Although there were not significant differences between recent incarceration and sexual risk for those with and without PTSD, incarceration was linked to some sexual risk behaviors regardless of PTSD symptoms. Among people with PTSD symptoms, there was a higher prevalence of sexual risk and depression symptoms, regardless of incarceration. These findings suggest a potentially compounding influence of PTSD symptoms and incarceration on sexual risk and infection among Black sexual minority men.

Effectiveness of trauma-focused cognitive behavioral therapy compared to psychosocial counseling in reducing HIV risk behaviors, substance use, and mental health problems among orphans and vulnerable children in Zambia: a community-based randomized controlled trial

Orphans and vulnerable children (OVC) in sub-Saharan Africa are at high risk for HIV infection and transmission. HIV prevention and treatment efforts with OVC are hindered by mental health and substance use problems. This randomized controlled trial compared a mental health intervention, Trauma Focused Cognitive Behavioral Therapy (TF-CBT), to an enhanced version of an existing HIV Psychosocial Counseling (PC+) program among 610 adolescents who met PEPFAR criteria for OVC and had HIV risk behaviors in Lusaka, Zambia. Outcomes included HIV risk behaviors (e.g., risky sexual behaviors), mental health (internalizing symptoms, externalizing behaviors, PTSD) and substance use. At 12-month follow-up, there were significant within group reductions in both groups for all outcomes, with the only significant between group difference being for substance use, in which OVC who received TF-CBT had significantly greater reductions than OVC who received PC+. In a subgroup analysis of OVC with high levels of PTSD symptoms, TF-CBT was superior to PC + in reducing internalizing symptoms, functional impairment, and substance use. Findings support TF-CBT for reducing substance use among OVC. Subgroup analysis results suggest that a robust intervention such as TF-CBT is warranted for OVC with significant mental and behavioral health comorbidities. The similar performance of TF-CBT and PC + in the overall sample for risky sexual behavior and mild mental health problems indicates that enhancing existing psychosocial programs, such as PC, with standard implementation factors like having a defined training and supervision schedule (as was done to create PC+) may improve the efficacy of HIV risk reduction efforts.Clinical Trials Number: NCT02054780.

Feasibility and acceptability of CRiSOL: A pilot peer-based intervention to address syndemic health issues afflicting Latino immigrants in the U.S

Substance use, HIV/AIDS, domestic violence and mental health (SAVAME) are syndemic health issues that disproportionately burden Latinos in the U.S. Yet, there are limited evidence-based interventions to address these interrelated syndemic issues and their shared socio-ecological determinants. This study sought to test the feasibility and acceptability of CRiSOL, a peer-based, resilience-focused intervention to reduce the impact of the SAVAME syndemic on Latino immigrants. Fifteen Latino immigrant community leaders were recruited and trained to serve as health promotion agents in their naturally existing social networks. The training was implemented with high fidelity, received with high satisfaction by the peer leaders, and associated with significant improvements in their knowledge, leadership skills, and social capital. During an 8-month outreach phase, nine leaders remained active in the program and documented 825 one-on-one interactions with community members, during which they provided advice/counseling (52.2% of interactions), health information/education (32.5%), referrals to health and social services (38.5%), food aid (39.9%), and service navigation/assistance (10.2%). While future research must be conducted to establish the effectiveness of CRiSOL, findings from this pilot evaluation indicate the feasibility, acceptability, and high level of reach of this intervention and suggest significant potential to reduce the SAVAME syndemic burden in Latino communities.

Protocol for a pilot randomized controlled trial of a telehealth-delivered counseling intervention to reduce suicidality and improve HIV care engagement in Tanzania

OBJECTIVE

Suicidal ideation is strikingly common among people living with HIV (PLWH) worldwide, leading to higher burden of disease, poor HIV care engagement, and loss of life. In low- and middle-income countries such as Tanzania, mental health resources are scarce, requiring innovative strategies for treatment. We describe the protocol for a clinical trial of a three-session telehealth counseling intervention to reduce suicidality and improve HIV care engagement in Tanzania.

METHODS

In a pilot randomized controlled trial, we will assess the feasibility, acceptability, and potential efficacy of a new telehealth intervention, termed "IDEAS for Hope". A total of 60 PLWH will be enrolled from two HIV clinics in the Kilimanjaro region and connected to telehealth counsellors based at a large regional hospital. Participants will be ≥18 years old and speak either Kiswahili or English. Patient screening will occur during routine HIV clinical care to identify PLWH experiencing suicidal ideation. Baseline surveys will be administered upon enrollment and participants will be randomized 1:1 to receive either IDEAS for Hope or the comparison condition, a brief safety planning session. All participants will receive an additional referral for psychiatric treatment. Follow-up assessment will occur at three months. IDEAS for Hope is informed by a Motivational Interviewing-enhanced safety planning intervention (MI-SafeCope) and our formative work in Tanzania. The model consists of Four Pillars: living healthy with HIV, managing HIV stigma, seeking social support, and meeting basic needs. Together, these mechanisms serve as a foundation for developing a sense of safety and hope for the future. Outcome measures will include intervention feasibility, acceptability, participant suicidality, and HIV care engagement.

SIGNIFICANCE

Innovative, telehealth-based counseling represents a promising treatment for suicidality among PLWH in low-resource settings. Results from this pilot trial will inform intervention refinement and parameter estimates for a future clinical trial powered to evaluate effectiveness.

The Relation between Depressive Symptoms and Unsafe Sex among MSM Living with HIV

In people living with HIV (PLWH), a positive association is often found between depressive symptoms and unsafe sex, which means sex without a condom. However, the results of such studies are inconclusive. The present study compared the numbers of safe and unsafe sexual contacts from men who have sex with men (MSM) (N = 159), living with HIV and attending a mental health clinic, with those of HIV-negative MSM in the general population (N = 198). We determined whether the presence of depressive symptoms was associated with unsafe sex in either of the two study populations. The depressive symptoms were measured with the Inventory of Depressive Symptoms (IDS), (MSM living with HIV) and with the 2012 Sexual Health Monitor (HIV-negative MSM). Finally, we determined whether MSM living with HIV with depressive symptoms, who received psychiatric treatment as usual, engaged in fewer unsafe sexual contacts one year after baseline. The mental-health-treatment-seeking MSM living with HIV engaged in more unsafe sexual contact than the MSM comparison group without HIV. Neither the treatment-seeking MSM living with HIV nor the MSM without HIV in the general population exhibited a relationship between depressive symptoms and unsafe sex. Moreover, the successful treatment of depressive symptoms in the treatment group did not lead to any reduction in the number of unsafe sexual contacts. Further research is needed to develop interventions that might be effective for MSM living with HIV with mental health symptoms to reduce the number of unsafe sexual contacts.

Examining Associations Between Mental Health, IPV Exposure, HIV Risk Behaviors, and PrEP Use in South African Women: An Analysis of Data from the Charisma Study

Intimate partner violence (IPV) has been associated with poorer mental health outcomes and increased human immunodeficiency virus (HIV) risk behaviors. We examine the relations between IPV, mental health symptomology (defined as psychological distress and alcohol misuse), and engagement in HIV risk behaviors among a sample of South African women who participated in a randomized controlled trial of CHARISMA, an intervention to increase women's agency to use oral pre-exposure prophylaxis (PrEP) safely and consistently as well as mitigate relationship challenges. We also examined the impact of trial participation on women's mental health, as well as the impact of psychological distress on the effectiveness of the CHARISMA intervention. Mental health symptomology and IPV exposure were prevalent and associated with some HIV risk and protective behaviors. Trial participation reduced psychological distress. There was no evidence for mental health symptomology impacting the effectiveness of the CHARISMA intervention.

High levels of mild to moderate depression among men who have sex with men and transgender women in Lima, Peru: implications for integrated depression and HIV care

ABSTRACTDepression disproportionally affects people at risk of acquiring or living with HIV and is associated with worse health outcomes; however, depression care is not routinely integrated with HIV prevention and treatment services. Selection of the best depression intervention(s) for integration depends both on the prevalence and severity of depression among potential users. To inform depression care integration in a community-based setting in Lima, Peru, we retrospectively analyzed routinely collected depression screening data from men who have sex with men and transgender women seeking HIV prevention and care services (N = 185). Depression was screened for using the Patient Health Questionnaire-9. Prevalence of any depression (PHQ-9 ≥ 5) was 42% and was significantly associated with the last sexual partner being "casual" (p = 0.01). Most (81%) depressive symptoms were mild to moderate (≥5 PHQ-9 ≤ 14). Integrating depression care with HIV prevention and treatment services in Peru should begin by implementing interventions targeting mild to moderate depression.

Associations between Early Psychosocial Deprivation, Cognitive and Psychiatric Morbidity, and Risk-taking Behavior in Adolescence

OBJECTIVE

Early psychosocial deprivation increases the risk of later cognitive and psychiatric problems, but not all deprived children show these difficulties. Here, we examine the extent to which psychosocial deprivation increases the risk of later cognitive and psychiatric difficulties and the downstream consequences of this for risk-taking behavior in adolescence.

METHOD

Children abandoned to institutions early in life were randomly assigned to care-as-usual or a foster care intervention during infancy. A separate group of never-institutionalized children was recruited as a comparison sample. The current follow-up study included 165 children (51% female), 113 with a history of institutionalization and 52 with no such history. At age 12, caregivers reported on children's psychiatric difficulties, and their IQ was assessed by standardized testing. At 16 years, risk-taking behavior was assessed from youth self-reports.

RESULTS

Latent profile analysis revealed three subgroups of children with varying levels of cognitive and psychiatric difficulties: Low-Morbidity (n = 104, 62.7%), Medium-Morbidity (n = 46, 27.9%), and High-Morbidity (n = 15, 9.4%). Nearly half of the institutionalized children belonged to the High- or Medium-Morbidity subgroups; and institutionally-reared children were significantly more likely to belong to one of these profiles than never-institutionalized children. Compared to the Low-Morbidity subgroup, membership in the Medium-Morbidity profile was associated with higher levels of risk-taking behavior at age 16 years.

CONCLUSIONS

Children who experience psychosocial deprivation are considerably more likely to present with elevated cognitive and psychiatric difficulties in early adolescence and, for some children, this elevation is linked to heightened risk-taking behavior in later adolescence.

Neuroinflammation in HIV-associated depression: evidence and future perspectives

People living with HIV face a high risk of mental illness, especially depression. We do not yet know the precise neurobiological mechanisms underlying HIV-associated depression. Depression severity in the general population has been linked to acute and chronic markers of systemic inflammation. Given the associations between depression and peripheral inflammation, and since HIV infection in the brain elicits a neuroinflammatory response, it is possible that neuroinflammation contributes to the high prevalence of depression amongst people living with HIV. The purpose of this review was to synthesise existing evidence for associations between inflammation, depression, and HIV. While there is strong evidence for independent associations between these three conditions, few preclinical or clinical studies have attempted to characterise their interrelationship, representing a major gap in the literature. This review identifies key areas of debate in the field and offers perspectives for future investigations of the pathophysiology of HIV-associated depression. Reproducing findings across diverse populations will be crucial in obtaining robust and generalisable results to elucidate the precise role of neuroinflammation in this pathophysiology.

ImpACT+, a coping intervention to improve clinical outcomes for women living with HIV and sexual trauma in South Africa: study protocol for a randomized controlled trial

Background

Addressing sexual trauma in the context of HIV care is essential to improve clinical outcomes and mental health among women in South Africa. Women living with HIV (WLH) report disproportionately high levels of sexual trauma and have higher rates of posttraumatic stress disorder. Adherence to antiretroviral therapy (ART) may be difficult for traumatized women, as sexual trauma compounds the stress associated with managing HIV and is often comorbid with other mental health disorders, further compromising care engagement and adherence. ART initiation represents a unique window of opportunity for intervention to enhance motivation, increase care engagement, and address the negative effects of trauma on avoidant coping behaviors. Mental health interventions delivered by non-specialists in low- and middle-income countries have potential to treat depression, trauma, and effects of intimate partner violence among WLH. This study will examine the effectiveness of Improving AIDS Care after Trauma (ImpACT +), a task-shared, trauma-focused coping intervention, to promote viral suppression among WLH initiating ART in a South African clinic setting.

Methods

This study will be conducted in Khayelitsha, a peri-urban settlement situated near Cape Town, South Africa. Using a hybrid type 1 effectiveness-implementation design, we will randomize 350 WLH initiating ART to the ImpACT + experimental condition or the control condition (three weekly sessions of adapted problem-solving therapy) to examine the effectiveness of ImpACT + on viral suppression, ART adherence, and the degree to which mental health outcomes mediate intervention effects. ImpACT + participants will receive six once-a-week coping intervention sessions and six monthly maintenance sessions over the follow-up period. We will conduct mental health and bio-behavioral assessments at baseline, 4, 8, and 12 months, with care engagement data extracted from medical records. We will explore scalability using the Consolidated Framework for Implementation Research (CFIR).

Discussion

This trial is expected to yield important new information on psychologically informed intervention models that benefit the mental health and clinical outcomes of WLH with histories of sexual trauma. The proposed ImpACT + intervention, with its focus on building coping skills to address traumatic stress and engagement in HIV care and treatment, could have widespread impact on the health and wellbeing of individuals and communities in sub-Saharan Africa.

Trial registration

Clinicaltrials.gov NCT04793217. Retrospectively registered on 11 March 2021.

Understanding the Prevalence and Associated Factors of Behavioral Intention of COVID-19 Vaccination Under Specific Scenarios Combining Effectiveness, Safety, and Cost in the Hong Kong Chinese General Population

BACKGROUND

The prevalence of coronavirus disease 2019 (COVID-19) vaccination is very critical in controlling COVID-19. This study mainly aimed to (1) investigate behavioral intentions of COVID-19 vaccination under various specific scenarios, and (2) associated factors of the afore-mentioned vaccination intentions.

METHODS

A random anonymous telephone survey interviewed 450 Chinese adults from September 16-30, 2020 in Hong Kong, China. Nine scenarios of behavioral intentions of COVID-19 vaccinations were measured combining effectiveness (80% versus 50%), safety (rare versus common mild side effect), and cost (free versus HK$ 500).

RESULTS

The prevalence of behavioral intentions of COVID-19 vaccination under the 9 specific scenarios was very low and varied greatly (4.2% to 38.0%). The prospective countries of manufacture also influenced vaccination intention (eg, Japan: 55.8% vs China: 31.1%). Only 13.1% intended to take up COVID-19 vaccination at the soonest upon its availability. The attributes of effectiveness and side effect influenced vaccination intention most. Positively associated factors of behavioral intentions of COVID-19 vaccination included trust/satisfaction toward the government, exposure to positive social media information about COVID-19 vaccines, descriptive norms, perceived impact on the pandemic, perceived duration of protectiveness, and life satisfaction.

CONCLUSION

Intention of COVID-19 vaccination was low in the Hong Kong general population, especially among younger people, females, and single people. Health promotion is warranted to enhance the intention. The significant factors identified in this study may be considered when designing such health promotion. Future research is required to confirm the findings in other countries. Such studies should pay attention to the specific context of cost, safety, and effectiveness, which would lead to different responses in the level of behavioral intention of COVID-19 vaccination (BICV).

Prevalence and correlates of common mental health problems and recent suicidal thoughts and behaviours among female sex workers in Nairobi, Kenya

BACKGROUND

Adverse childhood experiences (ACEs), poverty, violence and harmful alcohol/substance use are associated with poor mental health outcomes, but few studies have examined these risks among Female Sex Workers (FSWs). We examine the prevalence and correlates of common mental health problems including suicidal thoughts and behaviours among FSWs in Kenya.

METHODS

Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme (SWOP) clinics across Nairobi. Baseline behavioural-biological survey (n = 1003) data were collected June-December 2019. Mental health problems were assessed using the Patient Health Questionnaire (PHQ-9) for depression, the Generalised Anxiety Disorder tool (GAD-7) for anxiety, the Harvard Trauma Questionnaire (HTQ-17) for Post-Traumatic Stress Disorder (PTSD) and a two-item tool to measure recent suicidal thoughts/behaviours. Other measurement tools included the WHO Adverse Childhood Experiences (ACE) score, WHO Violence Against Women questionnaire, and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Descriptive statistics and multivariable logistic regression were conducted using a hierarchical modelling approach.

RESULTS

Of 1039 eligible FSWs, 1003 FSWs participated in the study (response rate: 96%) with mean age 33.7 years. The prevalence of moderate/severe depression was 23.2%, moderate/severe anxiety 11.0%, PTSD 14.0% and recent suicidal thoughts/behaviours 10.2% (2.6% suicide attempt, 10.0% suicidal thoughts). Depression, anxiety, PTSD and recent suicidal thoughts/behaviours were all independently associated with higher ACE scores, recent hunger (missed a meal in last week due to financial difficulties), recent sexual/physical violence and increased harmful alcohol/substance. PTSD was additionally associated with increased chlamydia prevalence and recent suicidal thoughts/behaviours with low education and low socio-economic status. Mental health problems were less prevalent among women reporting social support.

CONCLUSIONS

The high burden of mental health problems indicates a need for accessible services tailored for FSWs alongside structural interventions addressing poverty, harmful alcohol/substance use and violence. Given the high rates of ACEs, early childhood and family interventions should be considered to prevent poor mental health outcomes.

Heterosexual Cisgender Men Partnered with Transgender Women Exhibit Higher HIV/STI Sexual Risk than Their Gay, Bisexual, and Queer Counterparts: Findings from a U.S.-Based Convenience Sample Recruited Online

Cisgender men are frequently vectors for HIV transmission among transgender women. Despite this, the correlates of sexual risk among these men remain under-examined. The purpose of the present study was to explore potential differences in relationship characteristics, sexual risk-taking, and risk-reduction strategies among cisgender men partnered with transgender women. The study utilized secondary screening data provided by adult cis men who reported being in a primary relationship with a trans woman (N = 710). Gay men (18%) were comparatively older, and most likely to report both HIV seropositivity and committed pairings. Heterosexual men (14%) were more likely to report exchange sex, briefer relationships, extra-dyadic sex, lesser serostatus awareness or PrEP uptake. Queer men (7%) were youngest, and most likely to access PrEP. Heterosexual cis men with trans women partners may be subject to unique socio-cultural drivers of sexual risk, such as heteronormative pressures and relationship stigma.

Antiretroviral treatment adherence and mental disorders: observational case-control study in people living with HIV in Spain

Mental disorders hamper immunological control of HIV infection by exerting a negative influence on antiretroviral therapy (ART) adherence. We sought to address the possible relationship between non-adherence to antiretroviral treatment (ART), mental disorders and substance use in people living with HIV/AIDS (PLWHA) in Spain, which presents a high prevalence of intravenously transmitted HIV infection. We assessed 125 PLWHA attending regular outpatient follow-up. The main adherence measure was pill collection from the Hospital Pharmacy. We included sociodemographic variables, mental disorders diagnosis, and substance use in the 12 months prior to the assessment. Harmful alcohol consumption (OR: 6.834; 95% CI: 2.008-23.257; p = 0.002), suffering from depression (OR: 5.851; 95% CI: 1.470-23.283; p = 0.012) and being at risk of suicide (OR: 3.495; 95% CI: 1.136-10.757; p = 0.029) increased the likelihood of non-adherence. 29.6% of the sample had been infected via blood contact. HCV co-infection was present in 46.4% of the study sample, increasing the likelihood of non-adherence (OR: 3.223; 95% CI: 1.119-9.286; p = 0.030). Harmful alcohol use and some serious mental disorders (especially depression and suicide risk) are consistently associated with non-adherence to ART. HCV co-infection could be an important risk marker of non-adherence among PLWHA with a high prevalence of intravenous drug use.

Association between depression and HIV treatment outcomes in a US military population with HIV infection

Background

Depression is common among HIV-infected individuals and may contribute to suboptimal adherence to antiretroviral therapy (ART) and subsequent inability to attain viral load (VL) suppression. We evaluated associations between depression, self-reported adherence, and longitudinal HIV treatment outcomes in US Military HIV Natural History Study (NHS) participants with and without depression.

Methods

Male NHS participants with available ICD-9 data for mental health diagnoses, Center for Epidemiological Studies Depression (CES-D) measures, and self-reported adherence (SRA) were included. ART use was defined as ART initiation between 2006 and 2010, with follow-up through 2015. SRA was defined as taking 95% of ART doses and continuous ART was defined as longitudinal ART use with gaps  < 30 days. Continuous VL suppression was defined as maintaining VLs  < 200 c/mL on ART. To analyse the association between depression and HIV treatment outcomes, latent class analysis was used to create classes of depression trajectories: low depression (LD), recent onset depression (ROD) and high Depression (HD).

Results

Participants had a mean age of 32 (± 8.3) years at HIV diagnosis, and similar proportions were Caucasian (44.3%) or African American (40.8%). Overall, older participants at HIV diagnosis had greater odds of having 95% self-reported adherence (OR 1.06, 95% CI 1.02–1.12), and African Americans had lower odds (OR 0.41, 95% CI 0.22–0.76) compared to Caucasians (OR 1.49, 95% CI 0.52–4.28). However, there was no difference in SRA by depression trajectory. Participants with HD had an increased odds of taking ART continuously (OR 1.75, 95% CI 0.99–3.09), and those with ROD had significantly higher odds of virologic failure (OR 0.58, 95% CI 0.38–0.91).

Conclusions

Although there was no observed association between depression and SRA, participants with ROD had lower odds of attaining the HIV treatment goal of VL suppression. Continued efforts to identify and aggressively manage mental health disorders is important to success along the HIV care continuum.

HIV Related Knowledge, HIV Testing Decision-Making, and Perceptions of Alcohol Use as a Risk Factor for HIV among Black and African American Women

The HIV/AIDS epidemic disproportionately affects Black and African American women in the United States. This study examined the extent of HIV related knowledge, HIV testing decision-making, and perceptions of alcohol use as a risk factor for HIV among Black and African American women in urban and suburban communities. Seven focus groups were conducted with 37 women aged 18 to 49 residing in the Commonwealth of Massachusetts. Women participating in focus groups had a wide breadth of HIV related knowledge. Findings suggest the influence of interpersonal relationships and provider-patient interactions on HIV testing, the need for building community capacity and leveraging community resources towards HIV prevention, and the influence of alcohol outlet density on HIV vulnerability and exposure in communities of color. Comprehensive multifaceted evidence informed interventions that are culturally relevant and gender responsive are needed to reduce HIV/AIDS disparities.

Natural Language Processing of Clinical Notes to Identify Mental Illness and Substance Use Among People Living with HIV: Retrospective Cohort Study

Background

Mental illness and substance use are prevalent among people living with HIV and often lead to poor health outcomes. Electronic medical record (EMR) data are increasingly being utilized for HIV-related clinical research and care, but mental illness and substance use are often underdocumented in structured EMR fields. Natural language processing (NLP) of unstructured text of clinical notes in the EMR may more accurately identify mental illness and substance use among people living with HIV than structured EMR fields alone.

Objective

The aim of this study was to utilize NLP of clinical notes to detect mental illness and substance use among people living with HIV and to determine how often these factors are documented in structured EMR fields.

Methods

We collected both structured EMR data (diagnosis codes, social history, Problem List) as well as the unstructured text of clinical HIV care notes for adults living with HIV. We developed NLP algorithms to identify words and phrases associated with mental illness and substance use in the clinical notes. The algorithms were validated based on chart review. We compared numbers of patients with documentation of mental illness or substance use identified by structured EMR fields with those identified by the NLP algorithms.

Results

The NLP algorithm for detecting mental illness had a positive predictive value (PPV) of 98% and a negative predictive value (NPV) of 98%. The NLP algorithm for detecting substance use had a PPV of 92% and an NPV of 98%. The NLP algorithm for mental illness identified 54.0% (420/778) of patients as having documentation of mental illness in the text of clinical notes. Among the patients with mental illness detected by NLP, 58.6% (246/420) had documentation of mental illness in at least one structured EMR field. Sixty-three patients had documentation of mental illness in structured EMR fields that was not detected by NLP of clinical notes. The NLP algorithm for substance use detected substance use in the text of clinical notes in 18.1% (141/778) of patients. Among patients with substance use detected by NLP, 73.8% (104/141) had documentation of substance use in at least one structured EMR field. Seventy-six patients had documentation of substance use in structured EMR fields that was not detected by NLP of clinical notes.

Conclusions

Among patients in an urban HIV care clinic, NLP of clinical notes identified high rates of mental illness and substance use that were often not documented in structured EMR fields. This finding has important implications for epidemiologic research and clinical care for people living with HIV.

Childhood Sexual Trauma and Antiretroviral Therapy Adherence: A Mixed-Methods Systematic Review

Childhood sexual abuse (CSA) has been shown to be more prevalent among populations living with HIV. Antiretroviral therapy (ART) adherence is crucial for populations living with HIV as it significantly increases the likelihood of attaining and maintaining viral suppression. Previous findings on the association between CSA and ART adherence have been mixed. The current mixed-methods systematic review aimed to identify quantitative and qualitative studies from CINAHL, PsycInfo, PubMed, and Web of Science examining the relationship between CSA and ART adherence. Authors were also contacted if relevant data were unpublished. Studies had to be published from January 1, 2000 to April 1, 2019, written in English, and examined CSA as an exposure and ART adherence as an outcome. Four domains were combined: 1) childhood sexual abuse; 2) child; 3) antiretroviral; and 4) adherence. Eight quantitative and two qualitative studies were retained. The results showed that four quantitative studies found no association while the other four found factors such as timing of victimization, mental health and gender influenced the association between CSA and ART adherence. Themes emerging from the qualitative studies included use of ART evoking memories of CSA; CSA impacting mental health; and mental health treatment improving ART adherence. Mixed insights included the intricate links between CSA and ART adherence and the role of external factors on the relationship. ART adherence intervention programs may be needed for people who have experienced CSA. However, future studies are needed that will examine the association between CSA and ART adherence and include subgroup analyses.

Mental Health Services for Men Who Have Sex with Men in China

This study explores the presence of mental health challenges and related service utilization among MSM in China. An online cross-sectional survey recruited 520 MSM in Guangdong, China, to evaluate the participants' psychiatric symptoms, service fulfillment, and challenges. A high proportion of the participants experienced at least one psychiatric symptom in the past year, but less than half of their mental health service needs were fulfilled. The preferred agencies for mental health services were provincial and city-level general hospitals or primary health centers. Lack of knowledge and misconceptions of mental health services were the primary reasons for not receiving necessary services. Mental health service fulfillment was associated with younger age, lower education, higher income, local residency, cohabitation, and disclosure of MSM status. The high rate of mental health issues and gaps in service seeking indicates an urgent need to increase mental health awareness among MSM.

Resilience and Depression in Young Black Men Who Have Sex with Men: A Social-Ecological Model

Although the health of young Black men who have sex with men (YBMSM) is typically discussed in terms of HIV, they are significantly affected by depression. The present study explored protective and risk pathways to depressive symptoms among YBMSM within a social-ecological framework. A cross-sectional sample of 1,817 YBMSM in two large, southern cities in the United States completed a survey of sociodemographic characteristics as well as individual (e.g., resilience, internalized heterosexism) and contextual (e.g., peer social support, experiences of racism) factors. In cross-sectional analyses, structural equation modeling was used to examine whether there were indirect associations between contextual factors and depressive symptomology that were mediated by individual factors. Higher peer social support was associated with lower depressive symptoms via greater resilience; there was no direct association between peer social support and depressive symptoms when controlling for this indirect association. Additionally, there were indirect associations between several contextual risk factors and higher depressive symptoms via perceived HIV-related stigma and internalized heterosexism; some direct associations between contextual risk factors and higher depressive symptoms were significant when controlling for these indirect associations. Despite a number of risk factors for depression for YBMSM, resilience is a key protective factor that may play a critical role in the beneficial effects of peer social support. Broadly, findings suggest that public health efforts must continue to build upon and leverage YBMSM's community-based strengths in the service of improving their mental health and, indirectly, their physical health.

Turning the Lens Toward Emotions: Considering HIV-Positive Adolescent Mothers in South Africa

The idea that adolescence, an important developmental stage in human life is embodied in emotions is not new. However, the association between adolescence, unplanned motherhood, and HIV infection, which often lead to unanticipated transitions, may influence a rethink toward understanding the emotional and mental states of adolescent mothers. Using a sociological lens, this article draws on the concept of “emotionality” and the importance of paying attention to “emotions” in offering analysis of the new reality, which HIV-positive adolescent mothers find themselves in South Africa. Specifically, this article shifts the social research focus from behavioral (e.g. sexual behaviors) research to exploring HIV-positive adolescent mothers’ feelings, thus paying heed to a subjective emotional landscape. Through an inductive thematic analysis, the emotional accounts and unifying themes extracted from 13 (10 HIV-positive adolescent mothers and three key informants) semistructured in-depth interviews present an understanding of the various needs of an emerging youthful generation living with HIV, rather than a narrow, conventional focus on costs, risks, and impending mortality.

A Systematic Review and Meta-Analysis of Combination Behavioral Interventions Co-Targeting Psychosocial Syndemics and HIV-Related Health Behaviors for Sexual Minority Men

In the U.S., sexual minority men (SMM) are disproportionately affected by HIV. Interventions are needed to increase HIV prevention and treatment behaviors, especially among syndemically exposed SMM. In recent years, researchers have created and tested combination behavioral interventions co-targeting syndemics and HIV-related health behaviors. We evaluated that literature via systematic review and meta-analysis, identifying 44 trials targeting mental health symptoms, alcohol use, and drug use, as well as sexual risk behavior, antiretroviral adherence, and healthcare engagement. For the randomized controlled trials, we computed between-group, pre-post effect sizes and tested them via random-effects models. Results supported the efficacy of combined interventions with significant, small, positive effects for improving mental health and reducing substance use (d = .20, CIs: 0.12, .29), and reducing sexual risk behavior and improving antiretroviral adherence (d = .16, CIs: .03, .30). Stratification analyses indicate that longer (9+ sessions) and individual (vs. group) interventions resulted in stronger effects on syndemic but not health behavior outcomes. Intervention developers should attend to intervention intensity and format. More evidence is needed about the importance of additional factors, such as novel intervention targets and cultural tailoring, as well as broadening the focus to multi-level interventions to address both interpersonal and structural mechanisms of change.

Prevalence and correlates of probable depression diagnosis and suicidal ideation among patients receiving HIV care in Lilongwe, Malawi

Background

Depression and suicide ideation among people living with HIV (PLHIV) can threaten the success of HIV care and treatment programs, particularly within high HIV prevalence settings. We describe the prevalence and correlates associated with depression and suicidal ideation among PLHIV receiving HIV care in Lilongwe, Malawi.

Methods

From July to September 2013, 206 HIV clinic patients, who were ≥18 years of age and either pre-antiretroviral therapy (ART) or established on ART for ≥6 months prior to study, participated in a survey to assess the prevalence of a likely depressive disorder and suicidal ideation using the Patient Health Questionnaire-9. We explored factors associated with depression using bivariable linear regression and suicidal ideation using bivariable log-binomial regression.

Results

The prevalence of a likely depressive disorder and suicidal ideation was 12% (95% CI: 8%, 17%) and 16% (95% CI: 11%, 21%), respectively. Pre-ART patients (β=1.17, 95% CI: 0.03, 2.30, p-value=0.04) and those with problematic alcohol use (β=0.49, 95% CI: 0.07, 0.92, p-value=0.02) were associated with a higher depression severity. Suicidal ideation was relatively common (8%, 95% CI: 5%, 13%) among those without a likely depressive disorder and significantly correlated with having no primary, secondary, or tertiary education (β=-1.52, 95% CI: -2.46, -0.59, p-value<0.01).

Conclusions

Interventions that enhance identification and management of depressive disorders and suicidal ideation should be integrated within HIV care clinics in Malawi.

Women's perspectives on ImpACT: a coping intervention to address sexual trauma and improve HIV care engagement in Cape Town, South Africa

HIV-infected women who have experienced sexual violence face unique challenges in their HIV care engagement and adherence to antiretroviral medications (ARVs). Improving AIDS Care after Trauma (ImpACT) is a brief counseling intervention aimed at reducing the negative impact of sexual trauma and HIV, building coping skills, and improving long-term HIV care engagement. We conducted a randomized controlled pilot trial of ImpACT with 64 women initiating ARVs in Cape Town, South Africa, with results suggesting the intervention can reduce PTSD symptoms and increase motivation to adhere to ARVs. For the current study, we abstracted data from ImpACT worksheets completed by 31 participants during intervention sessions, and qualitative responses from post-intervention surveys, to examine mechanisms, facilitators, and barriers to change in the intervention. Data included participant descriptions of the values informing their care, barriers to participation, and perceived benefits of the intervention related to coping with trauma and improving care engagement. During the first session, women reported feelings of shame, sadness, and anger that led to social isolation, mistrust, and damaged relationships. Barriers to participation included work and school demands, issues with transportation, finances, and discomfort in talking about HIV and trauma, particularly in group sessions. Despite these challenges, several women stated they developed more positive thinking, felt more confident, and improved their interpersonal relationships. Participants also reported substantial positive impact on symptoms of sexual trauma and motivation to continue with long-term HIV care, and clearer understanding of barriers and facilitators to ARV adherence. ImpACT is a promising intervention model for building adaptive coping skills and adherence to HIV treatment, informed by personal values, among women with a history of trauma in this high-risk setting. The data also offer insights into strategies to strengthen the intervention, overcome barriers to participation, encourage the practical application of skills, and promote long-term HIV care engagement.

Relationship between depression and risk behaviors in a US Military population with HIV infection

This study evaluated the relationships between depression trajectories, depression diagnosis and sexual risk behaviors in the US Military HIV Natural History Study. Risk behavior survey data, a coded diagnosis of depression, available Center for Epidemiological Studies Depression measures, and self-reported depressive symptoms (n = 662) were utilized. Latent class analysis created 3 classes of depression trajectories, namely, low depression (LD, n = 378), recent-onset depression (ROD, n = 170), and high depression (HD, n = 114) trajectories. Overall, participants with clinically diagnosed depression were less likely to report often using condoms with new sexual partners in the past 3 months than those who have never been diagnosed with depression (OR 0.15, 95% CI 0.49-2.53). Participants with ROD (OR 0.52, 95% CI 0.28-0.97) and HD (OR 0.48, 95% CI 0.24-0.96) trajectories were less likely to report often using condoms with new sexual partners in the past 3 months than those with LD trajectories. Moreover, those with either ROD (OR 2.13, 95% CI 1.19-3.80) or HD (OR 2.74, 95% CI 1.43-5.24) trajectories were more likely to have had sex with ≥2 new sexual partners in the last 3 months than those with LD trajectories. Continued efforts targeting HIV-infected persons with mental health disorders are warranted to reduce sexual risk behaviors.

Depressive symptoms, physical symptoms, and health-related quality of life among older adults with HIV

PURPOSE

In the United States, approximately 45% of persons living with HIV (PLHIV) are ≥ 50 years of age. Many older PLHIV have multi-morbidities that complicate HIV infection and/or interfere with, or are exacerbated by, antiretroviral treatment. Physical health symptoms and psychiatric disorders, particularly depression, can worsen life quality in older PLHIV.

METHODS

This study assessed associations among physical symptoms, indicators of HIV-related health status (i.e., time since diagnosis; ever diagnosed with AIDS; having attained viral suppression), depressive symptoms, and health-related quality of life (HRQoL) in older PLHIV. Regression analyses examined data from 296 PLHIV ≥ 50 years of age living in Cincinnati, OH, Columbus, OH, and New York City.

RESULTS

Depressive symptoms and physical symptoms, particularly those related to appearance and sexual functioning, most strongly predicted HRQoL. Indicators of HIV health status did not significantly predict HRQoL. Depressive symptoms were a particularly robust predictor of HRQoL, even when accounting for physical health symptoms.

CONCLUSION

Findings suggest that symptom management is critical to HRQoL in older PLHIV, and symptoms related to physical appearance and sexual functioning should not be overlooked in this growing population.

Learning to address multiple syndemics for people living with HIV through client perspectives on CBT

OBJECTIVE

The mental health burden among people living with HIV/AIDS (PLWHA) is high and often involves multiple comorbid psychological and substance use-related psychosocial problems. These co-occurring problems, or syndemics, additively impair engagement in HIV disease management. Existing psychotherapies for mental health and HIV health have generally focused on a single psychosocial problem and little research exists to guide future psychotherapies that address multiple mental health issues.

METHOD

To address this gap in understanding, we conducted qualitative interviews with multiply comorbid PLWHA (N = 30) who completed cognitive-behavioural therapy (CBT) for depression and medication adherence.

RESULTS

Themes emerged regarding participants' perspectives on how overlapping substance use and mood disorders interacted to reduce the benefit of CBT. Substance use was a dominant theme compared to other syndemics, highlighting the need for integrated mental health and substance use interventions. Interviews also suggested modifications of which psychosocial concerns participants felt should be prioritized in treatment delivery. Finally, participants described content they would want in a psychotherapy intervention, including intimacy and sexual health.

CONCLUSIONS

Future psychotherapeutic interventions for syndemic problems and HIV self-care will need to comprehensively address complex concerns, including issues salient to the overall well-being of PLWHA. This may improve client engagement and, ultimately, mental, and physical health outcomes. Clinical or methodological significance of this article: Although mental health comorbidity is common and often complex among clients living with HIV, little research exists to guide psychotherapy for such intricate mental health concerns. The current study used content analysis of in-depth qualitative interviews with clients living with HIV and multiple mental health comorbidities who had recently completed cognitive-behavioural therapy. Recommendations based on these findings suggest strategies for clinicians working with similar clients to consider and offers suggestions for future treatment development research.

Correlates of Recent HIV Testing Among Transgender Women in Greater Kuala Lumpur, Malaysia

PURPOSE

In Malaysia, an estimated 9.7%-12.4% of transgender women (TW) are HIV positive, with higher estimates among those engaged in sex work. According to the 90-90-90 Joint United Nations Programme on HIV/AIDS strategy, HIV testing is the first crucial step in curbing the HIV epidemic. This study examines correlates of recent HIV testing among TW in Greater Kuala Lumpur, Malaysia.

METHODS

TW (N = 199) in Greater Kuala Lumpur completed a survey on healthcare access and utilization, including HIV testing history. Bivariate logistic regression and penalized multivariate logistic regression were used to explore correlates of HIV testing in the last 12 months.

RESULTS

Overall, 41.7% of TW reported having ever been tested for HIV. Among participants who were HIV negative or not sure of their HIV status (n = 187), only 18.7% (n = 35) had been tested for HIV in the last 12 months. The multivariate analysis indicated that having a primary care provider (PCP), being 26-40 years of age, and having higher mental health functioning were positively associated with recent HIV testing. Active amphetamine use and previous depression diagnosis were also associated with recent HIV testing.

CONCLUSION

HIV testing is the first step in linking individuals to prevention and treatment interventions. Our findings suggest that having a PCP can improve engagement in HIV testing. Moreover, PCPs can serve as a valuable link to HIV treatment and prevention services. Current interventions that target social and behavioral risk factors for HIV, on their own, may be insufficient at engaging all HIV-vulnerable TW.

Exploring Risk Factors Affecting the Mental Health of Refugee Women Living with HIV

Little is known about how the intersection of being a forced migrant and living with HIV can contribute to the development or exacerbation of pre-existing mental conditions. This study is set in this context and it aims to explore specific risk factors affecting the mental health of refugee women living with HIV. A total of eight refugee women living with HIV took part in the study; they were individually interviewed, and their transcripts were thematically analyzed. The overall findings indicated that participants’ mental health was impaired by multiple stressors associated with their conditions, such as racial discrimination, HIV-related stigma, including from health professionals, loneliness, and resettlement adversities. These all represent threats to public health, as they discourage individuals from engaging with adequate health/mental health services. Despite their situation, participants had not received psychological interventions and their healthcare was reduced to managing the physical symptoms of HIV. Participants indicated their need to take part in group interventions that could promote their mental health and social recovery. These findings are relevant to raising awareness about the specific risk factors affecting refugee women living with HIV and to provide evidence for public health interventions based on this specific population’s need.

Avoidant Coping Mediates the Relationship Between Self-Efficacy for HIV Disclosure and Depression Symptoms Among Men Who Have Sex with Men Newly Diagnosed with HIV

HIV diagnosis presents a critical opportunity to reduce secondary transmission, improve engagement in care, and enhance overall well-being. To develop relevant interventions, research is needed on the psychosocial experiences of newly diagnosed individuals. This study examined avoidant coping, self-efficacy for HIV disclosure decisions, and depression among 92 newly diagnosed men who have sex with men who reported recent sexual risk behavior. It was hypothesized that avoidant coping would mediate the relationship between self-efficacy and depression. Cross-sectional surveys were collected from participants 3 months after HIV diagnosis. To test for mediation, multiple linear regressions were conducted while controlling for HIV disclosure to sexual partners. Self-efficacy for HIV disclosure decisions showed a negative linear relationship to depression symptoms, and 99% of this relationship was mediated by avoidant coping. The index of mediation of self-efficacy on depression indicated a small-to-medium effect. Higher self-efficacy was related to less avoidant coping, and less avoidant coping was related to decreased depression symptoms, all else held constant. These findings highlight the role of avoidant coping in explaining the relationship between self-efficacy for HIV disclosure decisions and depression.

Healthcare providers' understanding of HIV serodiscordance in South Africa and Uganda: implications for HIV prevention in sub-Saharan Africa

HIV transmission within stable heterosexual HIV serodiscordant couples accounts for almost half the new incident infections in South Africa and Uganda. Advances in HIV prevention provide opportunities to reduce transmission risk within serodiscordant partnerships (e.g., antiretroviral treatment (ART), pre-exposure prophylaxis (PrEP), medical male circumcision, and couples-based HIV counselling and testing). These interventions require a clinical encounter with a provider who recognises prevention opportunities within these partnerships. We explored healthcare provider understanding of HIV serodiscordance in a reproductive counselling study with providers in eThekwini district, South Africa, and Mbarara district, Uganda. In eThekwini, in-depth interviews (29) and focus group discussions (2) were conducted with 42 providers (counsellors, nurses and doctors) from public sector clinics. In Mbarara, in-depth interviews were conducted with 38 providers (medical officers, clinical officers, nurses, peer counsellors and village health workers). Thematic analysis was conducted using NVivo software. In eThekwini, many providers assumed HIV seroconcordance among client partners and had difficulty articulating how serodiscordance occurs. Mbarara providers had a better understanding of HIV serodiscordance. In the two countries, providers who understood HIV serodiscordance were better able to describe useful HIV-prevention strategies. Healthcare providers require training and support to better understand the prevalence and mechanisms of HIV serodiscordance to implement HIV-prevention strategies for HIV serodiscordant couples.

Gender Moderates the Association of Depressive Symptoms to Sexual Risk Behavior Among HIV-Positive African-American Outpatients

Previous research has reported an association between depressive symptoms and sexual risk behavior. The purpose of this study was to explore whether gender moderates this association in a sample of HIV-positive African-Americans. Participants (N = 93) self-reported depressive symptoms (Center for Epidemiological Studies-Depression Scale; CES-D), and sexual risk behavior for the past 4 months. Analyses revealed that the depressive symptoms-by-gender interaction was associated with condomless sex and substance use proximal to sex. When analyses were stratified by gender, depressive symptoms were associated with condomless sex and frequency of substance use only for women. We conclude that depressive symptoms may be a more powerful sexual risk factor among women relative to men.

Reliability, Validity, and Factor Structure of the Hopkins Symptom Checklist-25: Population-Based Study of Persons Living with HIV in Rural Uganda

Depression and anxiety are highly comorbid among people living with HIV (PLHIV), but few instruments for screening or measurement have been validated for use in sub-Saharan Africa. The objective of this study was to determine the reliability, validity, and factor structure of the 25-item Hopkins Symptom Checklist (HSCL) in a population-based sample of PLHIV in rural Uganda. This study was nested within an ongoing population-based cohort of all residents living in Nyakabare Parish, Mbarara District, Uganda. All participants who identified as HIV-positive by self-report were included in this analysis. We performed parallel analysis on the scale items and estimated the internal consistency of the identified sub-scales using ordinal alpha. To assess construct validity we correlated the sub-scales with related constructs, including subjective well being (happiness), food insecurity, and health status. Of 1814 eligible adults in the population, 158 (8.7%) self-reported being HIV positive. The mean age was 41 years, and 68% were women. Mean HSCL-25 scores were higher among women compared with men (1.71 vs. 1.44; t = 3.6, P < 0.001). Parallel analysis revealed a three-factor structure that explained 83% of the variance: depression (7 items), anxiety (5 items), and somatic symptoms (7 items). The ordinal alpha statistics for the sub-scales ranged from 0.83 to 0.91. Depending on the sub-scale, between 27 and 41% of the sample met criteria for caseness. Strong evidence of construct validity was shown in the estimated correlations between sub-scale scores and happiness, food insecurity, and self-reported overall health. The HSCL-25 is a reliable and valid measure of mental health among PLHIV in rural Uganda. In cultural contexts where somatic complaints are commonly elicited when screening for symptoms of depression, it may be undesirable to exclude somatic items from depression symptom checklists administered to PLHIV.

The Development of a Brief Distress Reduction Intervention for Individuals Recently Diagnosed With HIV in China

In China, where there are few mental health resources, the majority of HIV-related efforts have focused on medical treatment and transmission prevention rather than psychosocial support. Yet people living with HIV/AIDS (PLWHA) report high levels of psychological distress, especially upon first receiving their HIV diagnosis. We conducted mixed methods research of a qualitative study with (N = 31) individual interviews and 3 focus groups (n = 6 in each group) of HIV-affected participants, and a quantitative survey (N = 200) with individuals living with HIV in Shanghai and Beijing, China. Our qualitative data revealed themes of forms of distress experienced and types of psychosocial support that our participants wished they could have accessed upon diagnosis as well as suggestions for intervention structure that would be most feasible and acceptable. Our quantitative surveys provided further evidence of the high degree of psychosocial distress among recently diagnosed PLWHA. Our findings informed the development of the Psychology Toolbox intervention, a brief CBT skills-based intervention comprising cognitive restructuring, behavioral activation, and paced breathing, designed to be integrated into primary care for recently diagnosed PLWHA. This study describes the intervention development process and contents of each session. Future research should evaluate the intervention for efficacy as well as examine best strategies for eventual implementation and dissemination.

Prevalence and Associations of Psychological Distress, HIV Infection and HIV Care Service Utilization in East Zimbabwe

The correlation between mental health and sexual risk behaviours for HIV infection remains largely unknown in low and middle income settings. The present study determined the prevalence of psychological distress (PD) in a sub-Saharan African population with a generalized HIV epidemic, and investigated associations with HIV acquisition risk and uptake of HIV services using data from a cross-sectional survey of 13,252 adults. PD was measured using the Shona Symptom Questionnaire. Logistic regression was used to measure associations between PD and hypothesized covariates. The prevalence of PD was 4.5% (95% CI 3.9-5.1%) among men, and 12.9% (95% CI 12.2-13.6%) among women. PD was associated with sexual risk behaviours for HIV infection and HIV-infected individuals were more likely to suffer from PD. Amongst those initiated on anti-retroviral therapy, individuals with PD were less likely to adhere to treatment (91 vs. 96%; age- and site-type-adjusted odds ratio = 0.38; 95% CI 0.15, 0.99). Integrated HIV and mental health services may enhance HIV care and treatment outcomes in high HIV-prevalence populations in sub-Saharan Africa.

The relation between mental health, homosexual stigma, childhood abuse, community engagement, and unprotected anal intercourse among MSM in China

The aim of the study was to explore the relation of various factors with unprotected anal intercourse (UAI) and provide some insight for HIV intervention on Chinese men who have sex with men (MSM). The current cross-sectional study recruited 365 MSM in Dalian, China. More than half of the respondents (117 respondents, 51.8% of the sample) had engaged in UAI. The multivariable logistic regression model suggested that poorer mental health (AOR: 7.16; 95% CI: 3.14–16.31), self-stigma (AOR: 1.53; 95% CI: 1.00–2.34), and experience(s) of physical abuse in childhood (AOR: 5.85; 95% CI: 1.77–19.30) were significantly and positively related to UAI. Community engagement was negatively associated with UAI (p < 0.05). It appears it is necessary to incorporate mental health services, eliminate the stigma against homosexuality, and facilitate MSM-related community engagement into intervention strategies to prevent UAI among Chinese MSM. Targeted UAI interventions in the subgroup with a history of childhood physical abuse should also be of great concern.

Internalized HIV stigma, bullying, major depressive disorder, and high-risk suicidality among HIV-positive adolescents in rural Uganda

BACKGROUND

Studies conducted in sub-Saharan Africa suggest a high prevalence of depression and suicidality among adolescents living with HIV (ALWH). This is an important public health issue because depression is known to compromise HIV treatment adherence. However, the drivers of depression and suicidality in this population are unclear. We conducted a cross-sectional study to estimate the associations between internalized stigma, bullying, major depressive disorder, and suicidality.

METHODS

We conducted a cross-sectional survey between November 2016 and March 2017, enrolling a consecutive sample of 224 ALWH aged 13-17 years. We collected information on demographic characteristics, internalized HIV-related stigma (using the six-item Internalized AIDS-Related Stigma Scale), bullying victimization (using the nine-item Social and Health Assessment Peer Victimization Scale), major depressive disorder [using the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID)], and suicidality (also using the MINI-KID). We fitted multivariable logistic regression models to estimate the associations between stigma, bullying, major depressive disorder, and suicidality.

RESULTS

Thirty-seven participants (16%) had major depressive disorder, 30 (13%) had suicidality, and nine (4%) had high-risk suicidality. Ninety-one participants (41%) had high levels of internalized stigma, while 97 (43%) reported two or more bullying events in the past year. In multivariable logistic regression models, major depressive disorder had a statistically significant association with bullying (AOR = 1.09; 95% CI 1.00-1.20; p = 0.04); while suicidality (low, moderate, high risk) had statistically significant associations with both bullying (AOR = 1.09; 95% CI 1.01-1.17; p = 0.02) and stigma (AOR = 1.30; 95% CI 1.03-1.30; p = 0.02).

CONCLUSIONS

Among ALWH in rural Uganda, stigma and bullying are strongly associated with major depressive disorder and suicidality. There is a need to incorporate psychological interventions in the mainstream HIV care to address these challenges for optimal management of HIV among ALWH.

Association between internalized stigma and depression among HIV-positive persons entering into care in Southern India

BACKGROUND

In India, which has the third largest HIV epidemic in the world, depression and HIV-related stigma may contribute to high rates of poor HIV-related outcomes such as loss to care and lack of virologic suppression.

METHODS

We analyzed data from a large HIV treatment center in southern India to estimate the burden of depressive symptoms and internalized stigma among Indian people living with HIV (PLHIV) entering into HIV care and to test the hypothesis that probable depression was associated with internalized stigma. We fitted modified Poisson regression models, adjusted for sociodemographic variables, with probable depression (PHQ-9 score ≥10 or recent suicidal thoughts) as the outcome variable and the Internalized AIDS-Related Stigma Scale (IARSS) score as the explanatory variable.

FINDINGS

521 persons (304 men and 217 women) entering into HIV care between January 2015 and May 2016 were included in the analyses. The prevalence of probable depression was 10% and the mean IARSS score was 2.4 (out of 6), with 82% of participants endorsing at least one item on the IARSS. There was a nearly two times higher risk of probable depression for every additional point on the IARSS score (Adjusted Risk Ratio: 1.83; 95% confidence interval, 1.56-2.14).

CONCLUSIONS

Depression and internalized stigma are highly correlated among PLHIV entering into HIV care in southern India and may provide targets for policymakers seeking to improve HIV-related outcomes in India.

Depression and ART Initiation Among HIV Serodiscordant Couples in Kenya and Uganda

Depression is a known barrier for antiretroviral therapy (ART) adherence, but less is understood about its effects on ART initiation. We followed 1013 HIV-infected individuals participating in the Partners Demonstration Project, an open-label study of integrated pre-exposure prophylaxis (PrEP) and ART delivery for HIV serodiscordant couples in Kenya and Uganda. Associations between depression, measured annually with the Hopkins Symptoms Checklist-Depression (HSCL-D), and ART initiation were assessed with Cox proportional hazards regression. At enrollment, 162 participants (16.0%) reported symptoms consistent with probable depression, defined by a HSCL-D mean score >1.75, and this proportion decreased during study follow-up (6.7 and 3.6% at 12- and 24-months, respectively; p value < 0.001). Greater depressive symptom severity was associated with a greater likelihood of ART initiation overall (adjusted hazard ratio [aHR] 1.32, 95% CI 1.01-1.73) and among participants with CD4 count ≤ 350 cells/µl (aHR 1.30, 95% CI 1.01-1.67). Depression decreased 6 months after ART initiation (adjusted odds ratio [aOR] 0.34, 95% CI 0.23-0.51). Among East African HIV-infected persons in HIV serodiscordant couples, depression was not a barrier to ART initiation. ART initiation was associated with improved depressive symptoms in this setting.

Demographic factors, mental health problems, and psychosocial resources influence women's AIDS risk

The aim of this study was to examine how depressive mood, posttraumatic stress disorder (PTSD) symptoms, self-efficacy, and social support are associated with HIV risk behaviors. Participants were sexually active women (N = 1488) recruited when attending gynecological consultations in primary care settings. Standardized questionnaires were administered to assess for depressive mood, abuse/assault-related PTSD, social support, self-efficacy, stress, and sexual risk behavior. The resulting association models showed that demographic factors, mental health problems, and resources are associated with sexual risk behavior. Detecting and treating mental health problems and interventions that bolster women's psychosocial resources are warranted.

Associations between depressive syndromes and HIV risk behaviors among San Francisco men who have sex with men

HIV prevention plans for men who have sex with men (MSM) are often multifaceted. They involve reduction of sexual risk behaviors, such as condomless intercourse, but also often include pharmaceutical approaches, such as early treatment of HIV-infected individuals with antiretroviral therapy (ART). Effectiveness is possibly threatened by individual-level factors, such as depression. In this study of 322 San Francisco MSM (240 HIV-uninfected individuals and 82 HIV-infected individuals, according to self-report), we examine associations between depressive syndromes and HIV risk behaviors (sexual risk behaviors and ART non-adherence). Our study failed to find evidence that depressive syndromes lead to increases in ART non-adherence (risk difference, RD: 27.9; 95% confidence interval, CI: -3.5, 59.3). However, the study does suggest an association between depressive syndromes and concurrence of non-adherence and potentially HIV-discordant condomless receptive anal intercourse (RD: 36.0; 95% CI: 5.2, 66.8). Among HIV-uninfected MSM, our study suggests negative associations between depressive syndromes and sexual risk behaviors. We recommend screening and treatment of depression among HIV-infected MSM.

The association between symptoms of mental disorders and health risk behaviours in Vietnamese HIV positive outpatients: a cross-sectional study

Background

A high prevalence of symptoms of mental disorders (SOMD) has been found among people living with HIV/AIDS (PLHIV). Additionally, SOMD may impact on the prevalence of high-risk health behaviours (HRB). This study investigates the relationship between SOMD and HRB in a large sample of Vietnamese HIV positive outpatients.

Methods

A cross-sectional study was conducted with 400 outpatients at two HIV/AIDS clinics in Ho Chi Minh City, Vietnam, selected using a systematic sampling technique. Validated scales were used to measure SOMD, specifically symptoms of depression, anxiety, alcohol use disorder (AUD), substance use disorder (SUD) and HIV associated dementia (HAD). Participants completed a self-report questionnaire assessing HRB during the preceding 12 months including unsafe sexual practices and illicit drug use. Multivariable logistic regression models were used to evaluate associations between SOMD and HRB.

Results

The majority of participants (63.5%) were male and the median age was 34.0 years. Unsafe sexual practices and illicit drug use were reported by 13.8 and 5.5% of participants. The prevalences of HAD, depression, AUD, anxiety and SUD symptoms were 39.8, 36.5, 13.3 10.5, 3.3% respectively. There was no association between SOMD and HRB either with or without adjusting for correlates of HRB, except between symptoms of SUD and illicit drug use. PLHIV who had symptoms of SUD were more likely to use illicit drugs (adjusted Odds Ratio 81.14, 95% CI 12.55–524.47).

Conclusions

While the prevalence of SOMD among HIV positive outpatients was high, most SOMD were not associated with increased HRB. Only illicit drug use was predicted by symptoms of SUD. Screening PLHIV for symptoms of SUD may be useful for detecting people likely to be engaging in illicit drug use to reduce the risk of secondary disease transmission.

Pre-Exposure Prophylaxis: A Narrative Review of Provider Behavior and Interventions to Increase PrEP Implementation in Primary Care

Since FDA approval of HIV pre-exposure prophylaxis (PrEP) for HIV prevention, attention has been focused on PrEP implementation. The CDC estimates that 1.2 million U.S. adults might benefit from PrEP, but only a minority are using PrEP, so there is a significant unmet need to increase access for those at risk for HIV. Given the large numbers of individuals who have indications for PrEP, there are not enough practicing specialists to meet the growing need for providers trained in providing PrEP. Moreover, since PrEP is a preventive intervention for otherwise healthy individuals, primary care providers (PCPs) should be primary prescribers of PrEP. There are important clinical considerations that providers should take into account when planning to prescribe PrEP, which are highlighted in the clinical case discussed. A growing body of research also suggests that some providers may be cautious about prescribing PrEP because of concerns regarding its "real-world" effectiveness, anticipated unintended consequences associated with its use, and ambiguity as to who should prescribe it. This review summarizes findings from studies that have assessed prescriber behavior regarding provision of PrEP, and offers recommendations on how to optimize PrEP implementation in primary care settings. Development and dissemination of educational interventions for PCPs and potential PrEP users are needed, including improved methods to assist clinicians in identifying appropriate PrEP candidates, and programs to promote medication adherence and access to social and behavioral health services. PCPs are well-positioned to prescribe PrEP and coordinate health-related services to improve the sexual health of their patients, but tailored educational programs are needed.

Prevalence, Recurrence, and Incidence of Current Depressive Symptoms among People Living with HIV in Ontario, Canada: Results from the Ontario HIV Treatment Network Cohort Study

Introduction

Current studies of depression among people living with HIV focus on describing its point prevalence. Given the fluctuating nature of depression and its profound impacts on clinical and quality-of-life outcomes, this study aimed to examine the prevalence, recurrence and incidence of current depressive symptoms and its underlying catalysts longitudinally and systematically among these individuals.

Methods

We conducted a prospective cohort study between October 1, 2007 and December 31, 2012 using longitudinal linked data sources. Current depressive symptoms was identified using the Centre for Epidemiologic Studies Depression Scale or the Kessler Psychological Distress Scale, first at baseline and again during follow-up interviews. Multivariable regressions were used to characterize the three outcomes.

Results

Of the 3,816 HIV-positive participants, the point prevalence of depressive symptoms was estimated at 28%. Of the 957 participants who were identified with depressive symptoms at baseline and who had at least two years of follow-up, 43% had a recurrent episode. The cumulative incidence among 1,745 previously depressive symptoms free participants (at or prior to baseline) was 14%. During the five-year follow-up, our multivariable models showed that participants with greater risk of recurrent cases were more likely to feel worried about their housing situation. Participants at risk of developing incident cases were also likely to be younger, gay or bisexual, and unable to afford housing-related expenses.

Conclusions

Depressive symptoms are prevalent and likely to recur among people living with HIV. Our results support the direction of Ontario’s HIV/AIDS Strategy to 2026, which addresses medical concerns associated with HIV (such as depression) and the social drivers of health in order to enhance the overall well-being of people living with or at risk of HIV. Our findings reinforce the importance of providing effective mental health care and demonstrate the need for long-term support and routine management of depression, particularly for individuals at high risk.

HIV Risk Behavior Among Methamphetamine Users Entering Substance Abuse Treatment in Cape Town, South Africa

South Africa is experiencing a growing methamphetamine problem, and there is concern that methamphetamine use may accelerate HIV transmission. There has been little research on the HIV prevention needs of methamphetamine users receiving substance abuse treatment in South Africa. This study assessed the prevalence and correlates of HIV risk behaviors among 269 methamphetamine users entering substance abuse treatment in two clinics in Cape Town. The prevalence of sexual risk behaviors was high among sexually active participants: 34 % multiple partners, 26 % unprotected intercourse with a casual partner, and 24 % sex trading for money/methamphetamine. The strongest predictor of all sexual risk behaviors was concurrent other drug use. Over half had not been HIV tested in the past year, and 25 % had never been tested, although attitudes toward HIV testing were overwhelmingly positive. This population of primarily heterosexual, non-injecting methamphetamine users is a high-risk group in need of targeted HIV prevention interventions. Substance abuse treatment is an ideal setting in which to reach methamphetamine users for HIV services.