Alcohol, But Not Depression or IPV, Reduces HIV Adherence Among South African Mothers Living with HIV Over 5 Years

Violence as an obstacle to HIV medication adherence and viral suppression: A daily diary investigation among adolescent boys

For the 1.6 million adolescents currently living with HIV, adherence to antiretroviral therapy (ART) is vitally important for reducing HIV-associated morbidity and mortality, and for preventing onward HIV transmission. Unfortunately, ART adherence is particularly low among adolescents. One important barrier to adherence is exposure to violence; however, the impact of cumulative versus acute exposure to violence on adherence is unclear. We tested whether violence exposure was associated with ART adherence and viral load over a one-year period among adolescent boys living with HIV in Soweto, South Africa. Participants (N = 239) completed weekly ecological momentary assessment (EMA) surveys of their recent experiences with violence and ART adherence. They provided biological samples at baseline and at the one-year follow-up to measure viral load. Higher average exposure to violence over the course of the study year was significantly associated with lower ART adherence (i.e., a cumulative impact). When we restricted violence exposure to intimate partner violence only, we found that participants were significantly less likely to take their HIV medication on days when they experienced physical intimate partner violence (i.e., an acute impact). We also found a significant positive association between exposure to violence over the course of the study and participants' viral load at follow-up, even after controlling for baseline viral load. Our findings suggest that violence impacts two important HIV care outcomes through multiple pathways and highlight the importance of differentiating cumulative versus acute victimization in violence research. To improve health outcomes among adolescents with HIV and prevent new infections, it will be necessary to include boys in violence prevention and support services and to address violence exposure in HIV care.

Why do Integrated Maternal HIV and Infant Healthcare Services work? A Secondary Analysis of a Randomised Controlled Trial in South Africa

In a randomised trial, we found that integrated maternal HIV and infant health services through the end of breastfeeding were significantly associated with the primary outcome of engagement in HIV care and viral suppression at 12 months postpartum, compared to the standard of care. Here, we quantitatively explore potential psychosocial modifiers and mediators of this association. Our findings suggest that the intervention was significantly more effective among women experiencing an unintended pregnancy but did not improve outcomes among women reporting risky alcohol use. Although not statistically significant, our results suggest that the intervention may also be more effective among women experiencing higher levels of poverty and HIV-related stigma. We observed no definitive mediator of the intervention effect, but women allocated to integrated services reported better relationships with their healthcare providers through 12 months postpartum. These findings point to high-risk groups that may benefit the most from integrated care, as well as groups for whom these benefits are hampered and that warrant further attention in intervention development and evaluation.

In the era of universal test and treat in Uganda, recent intimate partner violence is not associated with subsequent ART use or viral suppression

Intimate partner violence (IPV) has been associated with delays throughout the HIV care continuum. This study explored prospective associations between experiences of past-year IPV and two HIV care outcomes in the context of current universal test and treat guidelines using two consecutive rounds of an ongoing HIV surveillance study conducted in the Rakai region of Uganda. Longitudinal logistic regression models examined associations between IPV, use of antiretroviral therapy (ART) and viral load suppression (VS), adjusting for outcome variables at baseline. To address differences in ART retention by IPV, propensity scores were used to create inverse-probability-of-treatment-and-censoring-weighted (IPTCW) models. At baseline, of 1923 women with HIV (WWH), 34.6%, 26.5%, 13.5% reported past-year verbal, physical and sexual IPV; a lower proportion of persons who experienced physical IPV (79.4%) were VS than those who did not (84.3%; p = 0.01). The proportion VS at baseline also significantly differed by exposure to verbal IPV (p = 0.03). However, in adjusted longitudinal models, IPV was not associated with lower odds of ART use or VS at follow-up. Among WWH in the Rakai region, IPV does not appear to be a barrier to subsequent ART use or VS. However, given the prevalence of IPV in this population, interventions are needed.

Intimate Partner Violence and Engagement in the HIV Care Continuum among Women in Sub-Saharan Africa: A Prospective Cohort Study

Research suggests that women's experience of intimate partner violence (IPV) is associated with poor engagement in HIV care and treatment. However, most studies have been cross-sectional and conducted in North America. We examined the association between physical IPV and HIV care outcomes in a prospective cohort study of women living with HIV (WLHIV) in Malawi, South Africa, Uganda, and Zimbabwe. At enrollment, 15% of the 351 participants self-reported physical IPV. IPV experience was not associated with time to first engagement in HIV care or the proportion virally suppressed after 6 months on ART. Women reporting physical IPV were less likely to initiate ART within 6 months of becoming eligible (adjusted RR 0.74, 95% CI 0.53-1.03). IPV screening is critical to identify survivors and link them to appropriate services. However, addressing IPV may not increase engagement in HIV care or viral load suppression among WLHIV in sub-Saharan Africa.

Perinatal alcohol use among young women living with HIV in South Africa: Context, experiences, and implications for interventions

Perinatal alcohol use is common in South Africa, including among young women living with HIV (WLHIV), but there are few insights into the drivers of alcohol use in this population. Following the completion of a pilot trial of a peer support intervention for WLHIV aged 16-24 years in Cape Town, we purposively selected participants who had reported perinatal alcohol use at ≥1 study visits to complete a qualitative in-depth interview exploring their experiences of substance use. Of 119 women enrolled, 28 reported alcohol use, and 24 were interviewed, with ≥1/3 reporting drinking throughout their pregnancy. Women described living in a community where heavy perinatal alcohol consumption is normalised, including among their peers, leading to social pressure. Despite being aware of the risks of perinatal alcohol use, women described a disconnect between public health messaging and their experiences. Although most acknowledged the negative effects of alcohol in their lives, self-efficacy to reduce consumption was diminished by peer influences and the lack of formal employment and opportunities for recreation. These findings provide insights into the drivers of perinatal alcohol use in this setting, and suggest that without meaningful community-level changes, including employment opportunities and alternatives for socialising, interventions may have limited impact.

Factors Associated With Changes in Alcohol Use During Pregnancy and the Postpartum Transition Among People With HIV in South Africa and Uganda

Identifying factors associated with alcohol use changes during pregnancy is important for developing interventions for people with HIV (PWH). Pregnant PWH (n = 202) initiating antiretroviral therapy in Uganda and South Africa completed two assessments, 6 months apart (T1, T2). Categories were derived based on AUDIT-C scores: "no use" (AUDIT-C = 0 at T1 and T2), "new use" (AUDIT-C = 0 at T1, >0 at T2), "quit" (AUDIT-C > 0 at T1, =0 at T2), and "continued use" (AUDIT-C > 0, T1 and T2). Factors associated with these categories were assessed. Most participants had "no use" (68%), followed by "continued use" (12%), "quit" (11%), and "new use" (9%). Cohabitating with a partner was associated with lower relative risk of "continued use." Borderline significant associations between food insecurity and higher risk of "new use" and between stigma and reduced likelihood of "quitting" also emerged. Alcohol use interventions that address partnership, food security, and stigma could benefit pregnant and postpartum PWH.

Hazardous or harmful alcohol use and reward processing in people with HIV

The intersecting epidemics of HIV and hazardous or harmful alcohol use (HAU) can have significant detrimental consequences. Both HIV and HAU have independent negative influences on executive function. Dysfunction in reward processing may play a role in these co-occurring epidemics. In this cross-sectional case-control study, we investigated the association of HAU with reward processing amongst people with HIV (PWH). We investigated the function of the ventral-striatal reward system using a functional MRI (fMRI) monetary incentive delay (MID) task in a sample of 60 South African adults (mean age 32.7 years): 42 living with HIV and on ART (21 with harmful alcohol use [HIV + HAU], 21 without [HIV-HAU]) and 18 healthy controls, matched for age, gender, and resident community. Education significantly influenced task performance, with those with a secondary level of education demonstrating a greater increase in reaction time (p = 0.048) and accuracy (p = 0.002) than those without. There were no significant differences in reward anticipation in the ventral striatum (VS) between HIV + HAU, HIV-HAU, and healthy controls when controlling for level of education. There were also no significant differences in reward outcome in the orbitofrontal cortex (OFC) between HIV + HAU, HIV-HAU, and healthy controls when controlling for level of education. In a sample of South African adults, we did not demonstrate significant differences in reward anticipation in the VS and reward outcome in the OFC in PWH, with and without HAU, and controls. Factors, such as task performance, education, and depression may have influenced our results. Further studies are needed to better delineate the potential links between HIV, HAU, and depression and reward system function.

Impact of adverse childhood experiences on women's psychosocial and HIV-related outcomes and early child development in their offspring

Adverse childhood experiences (ACEs) may have a critical influence on adult outcomes and subsequent offspring development, but few data have explored the effects of ACEs in low-resource settings where the burdens of childhood adversity and HIV are high. Among mothers living with HIV in Cape Town, we examined the effects of ACEs on maternal psychosocial and HIV-related outcomes, as well as early child development in their offspring aged 36-60 months. The World Health Organization's Adverse Childhood Experiences International Questionnaire was used to measure maternal reports of ACEs, and the Ages & Stages Questionnaire to screen for developmental delays in their offspring. Among 353 women (median age: 32 years), 84% reported ≥1 ACEs. Increased report of ACEs was strongly associated with depressive symptoms, hazardous alcohol use, intimate partner violence and self-reported suboptimal adherence to antiretroviral therapy. These associations were driven by more severe childhood experiences, including abuse, neglect and exposure to collective violence. Among 255 women who reported on their child's development, maternal ACEs were associated with poorer socioemotional development. These data suggest that childhood adversity has long-term effects on maternal outcomes as well as their children's socioemotional development and point to ACEs that might be targeted for screening and intervention.

Perceived Barriers to HIV Care and Viral Suppression Comparing Newly Diagnosed Women Living with HIV in Rural Uganda with and without a History of Intimate Partner Violence

Intimate partner violence (IPV) is associated with poor HIV care linkage and retention, medication adherence, and viral suppression. However, limited knowledge exists regarding potential mechanisms linking IPV to these outcomes. We aimed to (a) identify the top barriers to accessing HIV care experienced by women living with HIV (WLHIV) who report a history of IPV and have suppressed viral load (VL) versus unsuppressed VL and (b) understand how these barriers influence VL, comparing WLHIV with a history of IPV to WLHIV without a history of IPV. Study data come from newly diagnosed WLHIV in rural Uganda participating in the standard-of-care control arm of a randomized trial (n = 152). Descriptive results ranking mean scores from highest to lowest showed that, among women with a history of IPV, irrespective of viral suppression status, paying for transportation to come to clinic, having to wait at the clinic for long periods of time, and finding a clinic within reasonable travel distance were the top three barriers to accessing HIV care. WLHIV with a history of IPV were significantly more likely to have unsuppressed VL versus suppressed VL if they reported higher levels of difficulty finding a clinic within reasonable travel distance (RRR = 1.7, 95% CI [1.1-2.7]), getting permission to take time off from work (RRR = 1.5, 95% CI [1.0-2.9]), and finding time to come to the clinic for an appointment (RRR = 1.6, 95% CI [1.0-2.6]). The same relationships were not present among WLHIV without a history of IPV, suggesting these barriers and their effect on VL may be uniquely related to IPV. Interventions should address IPV and HIV care continuum outcomes in tandem, targeting barriers to accessing HIV care likely associated with IPV. Additional research is necessary to better understand how IPV relates to HIV care barriers and VL.

Intimate partner violence and the HIV care and treatment cascade among adolescent girls and young women in DREAMS, South Africa

Supplemental Digital Content is Available in the Text.

Background:

Intimate partner violence (IPV) may affect the HIV-treatment cascade.

Setting:

Four high HIV-prevalence DREAMS health districts in South Africa.

Methods:

Secondary analysis of cross-sectional data collected March 2017–June 2018, using random household sample of young (12–24 years) girls and women. Face-to-face interviews assessed IPV and HIV-status knowledge, and finger-prick blood draws assessed ART (antiretroviral therapy) uptake and viral suppression. We used logistic regression to estimate crude and adjusted effects of IPV on HIV knowledge, ART uptake, and viral suppression.

Results:

Of 18,230 adolescent girls and young women, 8413 (46%) reported ever having had sex, of whom 1118 (13%) were HIV positive. The 90:90:90 benchmarks were 61% knew their status, 86% had ART present in their blood sample, and 91% were virally suppressed. Among the entire sample of young women living with HIV, 65.6% were virally suppressed. Past year IPV was reported by 15%. In adjusted models, IPV trended toward increasing the odds that a young woman was aware she was living with HIV [adjusted odds ratios (aOR) = 1.40, 2.00–9.98, P = 0.067]. There was no association between IPV and reduced treatment use (aOR = 0.73, 0.41–1.29). IPV was independently associated with reduced viral suppression (aOR = 0.30, 0.13–0.66).

Conclusions:

Addressing the role of IPV in undermining the treatment cascade for adolescent and young women is a critical issue for HIV programming.

Psychic suffering and depression in black children and adolescents: systematic review and meta-analysis

Depression is a common disorder in the population, but some people are more vulnerable to this condition. Groups at higher risk of developing psychic suffering include black children and adolescents living in vulnerable socioeconomic conditions. This study aimed to analyze race and life conditions as determinants of depression in children and adolescents. This was a systematic review with meta-analysis. The study sources were MEDLINE Ovid, Web of Science, Latin American and Caribbean Health Science Information database, Science Citation Index-Expanded, PubMed, EMBASE, and Scopus. The following keywords were used: Child, Adolescent, Stress, Psychological, Depression, and African Continental Ancestry Group, using the logical operators AND and OR. The general criteria were observational studies published in the last 20 years. Language was not restricted to avoid possible bias in the selection of articles. Studies with a high risk of bias were excluded. General analysis was conducted with RStudio 3.0 software using odds ratio analysis with a 95% confidence interval and 0.05 significance level. We firstly found 654 studies, of which 18 met the criteria and were included in this review. Race and life conditions were determinants of depression in children and adolescents, with a negative impact for the black population.

Longitudinal association between intimate partner violence and viral suppression during pregnancy and postpartum in South African women

OBJECTIVE

We examined the longitudinal association between women's exposure to intimate partner violence (IPV) and HIV viral load during pregnancy and postpartum.

DESIGN

Secondary analysis of an HIV-positive cohort enrolled during pregnancy at a South African antenatal clinic.

METHODS

Viral load was assessed at 10 study visits and analyzed continuously as log10 copies/ml and suppression at less than 50 copies/ml. IPV was measured at three timepoints using behaviorally specific items. We used multivariate logistic regression to examine the association between IPV and viral suppression, and cross-lagged dynamic panel modeling (DPMs) to estimate the longitudinal association between IPV (lagged by 3-6 months) and log10 viral load.

RESULTS

Of 471 women, 84% were virally suppressed by 6 weeks postpartum and 67% at 12 months postpartum. One-third reported IPV exposure. IPV victimization was not associated with viral suppression at delivery, but was associated with a reduced odds of viral suppression at 12 months postpartum (aOR = 0.48, 95% CI = 0.27-0.85). Findings were robust to sensitivity analyses at different timepoints and clinical cut-points. In DPMs, lagged IPV exposure was associated with higher log10 viral load after controlling for past viral load, duration on ART, age, alcohol use, and gestation at study enrolment. Each standardized increase in IPV intensity was associated with higher log10 viral load (standardized coefficient = 0.12, 95% CI = 0.05-0.23).

CONCLUSION

Although viral suppression was widely achieved during pregnancy, suppression rates declined postpartum in this South African cohort. These data suggest IPV is longitudinally associated with elevated viral load postpartum. Interventions for reducing exposure to IPV are important for the health of women and may improve HIV care and treatment.

Immunological and Psychological Efficacy of Meditation/Yoga Intervention Among People Living With HIV (PLWH): A Systematic Review and Meta-analyses of 19 Randomized Controlled Trials

BACKGROUND

An expanding number of mind-body therapies are being used to reduce the psychological burden of peoples living with human immunodeficiency virus (HIV). However, the effects on the immune system and mental health varied among studies.

PURPOSE

This meta-analysis was conducted to summarize the randomized controlled trials to draw comprehensive conclusions regarding the psycho-immunological efficacy.

METHODS

Random-effects models were used to assess the outcome of interest. Egger's tests were used to identify publication bias. Subgroup and meta-regression were used to explore potential moderators. This review was registered on the PROSPERO database (CRD42019148118).

RESULTS

Nineteen randomized controlled trials with a total sample size of 1,300 were included in this meta-analysis. Regarding immune system outcome, mind-body therapy significantly improved CD4 T-cell counts (Cohen's d = 0.214, p = .027) and maintained (0.427, p = .049). In addition, baseline CD4 T-cell counts and years since HIV diagnosis significantly moderated the efficacy of mind-body practices on CD4 improvement (all ps < .001). Regarding mental health outcome, mind-body therapy significantly reduced stress, depression, and anxiety symptoms (0.422, p < .001; 0.506, p < .001, and 0.709, p < .001, respectively) while improving quality of life (0.67, p < .001).

CONCLUSIONS

Meditation/yoga intervention could result in potential benefits with regard to improved CD4 T-cell counts immediately after the intervention and at long-term follow-up, while also improving their mental health. The cost-effective meditation/yoga intervention should be integrated into routine care for people living with HIV, especially for those with lower CD4 baseline and fewer years since diagnosis.

Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda

INTRODUCTION

We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa.

METHODS

We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status.

RESULTS

In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/mm3 ). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIV-RNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women.

CONCLUSIONS

Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.