A Pilot Study of a Mobile Intervention to Support Mental Health and Adherence Among Adolescents Living with HIV in Western Kenya

Prevalence and Determinants of Viral Suppression in Young People Living with HIV on Antiretroviral Therapy in Southern Africa: A Cross-Sectional Analysis of HIV Survey Data of 2020 and 2021

Young People Living with HIV (YPLHIV, 15-24 years) are an important demographic of Persons Living with HIV (PLHIV) globally and in Southern Africa. However, YPLHIV experience poor outcomes across the HIV diagnostic and treatment cascade due to multiple factors. We estimated the prevalence and determinants of HIV viral suppression in YPLHIV on antiretroviral therapy (ART) in selected Southern African countries. We used publicly available data from Malawi, Zimbabwe, Mozambique, Lesotho, and Eswatini collected during the Population-based HIV Impact Assessments (PHIAs) of 2020 to 2021. Weighted proportions, and 95% confidence intervals (CI) were computed to estimate the prevalence of viral suppression (< 1000c/ml) and bivariate and multivariate analyses were conducted to identify determinants of viral suppression. A total of 855 records of YPLHIV on ART were included in the analysis. The prevalence of viral suppression in YPLHIV on ART was 82.4% (95% CI: 76.7, 86.9). Residing in Mozambique and duration on ART were inversely associated with viral suppression; adjusted odds ratios (AORs) of 0.37 (95% CI: 0.14, 0.95), and 0.87 (95% CI: 0.80, 0.94), respectively. A negative result in the depression screen, being married/cohabitating, and ever switching an ART regimen were positively associated with viral suppression: AORs of 5.78 (95% CI: 2.21, 15.11), 3.72 (95% CI: 1.44, 9.63), and 3.44 (95% CI: 1.69, 7), respectively. YPLHIV had suboptimal viral suppression lower than the UNAIDS 95% targets and may benefit from further research and tailored interventions addressing modifiable factors associated with viral suppression such as depression.

Mental Health Interventions for Young People Living With HIV/AIDS in Sub-Saharan Africa: A Systematic Review

Introduction: Young people (aged 15-24) living with HIV/AIDS (YPLHIV) in sub-Saharan Africa (SSA) experience higher rates of mental health conditions compared to their uninfected peers. Research and practitioners have expressed interest in designing and implementing mental health interventions to improve the mental health and well-being of this vulnerable population. However, there is limited effort to systematically synthesize existing evidence on mental health interventions for YPLHIV to address salient questions relating to effectiveness, characteristics, practice issues among others to inform practice, and future research endeavors. This systematic review was conducted to take stock and synthesize existing data to address the above issues. Methods: This review was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy was implemented, utilizing five electronic databases and gray literature repositories. Studies (1) from SSA that focused on young adults with HIV/AIDS and (2) examined the effectiveness of interventions designed to enhance mental health outcomes and treatment adherence were included. Two independent reviewers were involved in the study selection, data extraction, and quality assessment, resolving discrepancies by consensus or consultation. Data were presented using narrative syntheses. Results: Eight studies met the inclusion criteria, with a total sample size of 1510 participants, reporting on interventions from six African countries. The interventions were categorized as follows: cognitive behavioral therapy-based, family-based, peer support, and community-based. The interventions showed mixed effectiveness for depression, with three studies demonstrating significant improvements while four showed no substantial change. The only study on improving anxiety reported promising results. Four interventions positively influenced ART adherence, although with varying magnitudes. Peer support, family-based approach, and digital (mobile phone) approaches were identified as effective strategies. Conclusions: The review showed promising approaches to improve mental health in YPLHIV, namely, through peer support, family-based, and digital (i.e., mobile phone) approaches. Although the results were mixed for depression and limited but positive for anxiety, several interventions improved ART adherence. However, the modest evidence base and varied measurement approaches necessitate more research across SSA.

Feasibility of smartphone-enabled asynchronous video directly observed therapy to improve viral suppression outcomes among HIV unsuppressed children and adolescents in Kenya

BACKGROUND

Video directly observed therapy (VDOT) has been used as an acceptable, cost-effective, client-centered intervention for tuberculosis management. VDOT targeting children (0-14 years) and adolescents (15-19 years) living with HIV (CALHIV) not achieving viral suppression (VS) [i.e., < 1000 copies/ml] was piloted in 73 facilities in Kenya. We conducted a feasibility study on the utilization and re-suppression rates of clients enrolled in VDOT.

METHODS

A review of data from 223 virally unsuppressed clients aged between 0-19 years on antiretroviral therapy (ART) who were enrolled to use the VDOT application daily for at least 12 weeks between February 2021 and October 2022 at 73 health facilities was conducted. Clients stopped using the application upon achieving VS. VS was assessed after at least 12 weeks of VDOT follow-up through self-care or healthcare worker (HCW)-led approaches. Using a multivariable Cox Proportional Hazards regression model, we assessed demographic and clinical determinants of VS presenting adjusted hazard ratios (aHR).

RESULTS

Most users, 163 (73.1%) were adolescents aged 10-19 years. Only 19 (8.5%) were on self-care VDOT. Median time on follow-up was 19 weeks, with 126 videos uploaded, and 75% VDOT adherence. Over three-fourths, 176 (78.9%) had achieved VS during follow-up. Results showed a higher likelihood of VS among children on once-daily compared to twice-daily ARV dosage, aHR = 2.51 (95% CI: 2.06 - 3.05), and those on second- or third-line regimens compared to those on first-line regimens, aHR = 3.05 (95% CI: 1.78 - 5.22). Similarly, those on a DTG-based regimen had a higher likelihood of VS compared to those on LPV/r-based, ATV/s-based, or EFV-based regimens, aHR = 1.95 (95% CI: 1.25 - 3.06). Children receiving care from guardians and siblings had a higher likelihood of VS compared to those receiving care from parent caregivers, 1.61 (95% CI: 1.27-2.03), and 2.00 (95% CI: 1.12 - 3.57), respectively.

CONCLUSION

VDOT supported the achievement of VS among unsuppressed CALHIV on antiretroviral treatment and was significantly associated with dosage frequency, antiretroviral regimen, first- or second-line therapy, antiretroviral regimen classification, and type of caregiver. Findings suggest the utility of VDOT among unsuppressed CALHIV in resource-limited settings.

Experiences and perceptions on antiretroviral therapy adherence and non-adherence: a scoping review of young people living with HIV in sub-Saharan Africa

BACKGROUND

Young people in sub-Saharan Africa (SSA) shoulder a disproportionate burden of global HIV. We conducted a scoping review to map the research on the experiences and perceptions of young people living with HIV (YPLHIV) on antiretroviral therapy (ART) in SSA to inform future research.

METHODS

Following scoping review guidelines, we searched PubMed, Web of Science, EBSCOhost including Academic Search Complete, APA PsycInfo, Health Source: Nursing/Academic Edition, Medline with Full-text, Scopus and ScienceDirect for papers on YPLHIV adhering and not adhering to ART in SSA. We included literature published between 1 January 2010 and 30 September 2022. Search terms employed were adherence, non-adherence, and related synonyms. Bibliometric data and themes describing factors influencing the experiences and perceptions of ART adherence and non-adherence were extracted.

RESULTS

Of the 2671 papers identified, 22 papers from 12 countries were included. Studies employed quantitative (3), mixed (6), and qualitative (13) methods. Most publications concentrated on barriers to adherence rather than enablers. Factors affecting ART adherence and non-adherence were psychosocial, emotional, self-management, support, financial and structural. YPLHIV also faced problems with the responsiveness of health services and access to information.

CONCLUSIONS

We identified multiple factors surrounding ART adherence and non-adherence impacting the health and wellbeing of YPLHIV. The review findings showed the importance of research to improve the understanding of the relationships that YPLHIV in SSA develop with ART in adolescence and factors that facilitate adherence. Psychosocial adherence support and patient-centred care approaches are required.

Acceptability of an online peer support group as a strategy to improve antiretroviral therapy adherence among young people in Kampala district, Uganda: qualitative findings

INTRODUCTION

Peer support groups may contribute to adherence and play a role in decreasing the stigma of antiretroviral therapy (ART) adherence among young people living with HIV (YPLHIV). However, peer support activities usually occur face-to-face in Uganda and elsewhere in Sub-Saharan Africa and thus have structural limitations and may not be readily available when young people need them. Online peer support has the potential to help YPLHIV access regular psychosocial support without significant effort or cost. We assessed the acceptability of a WhatsApp peer support group as a strategy to improve ART adherence among Ugandan YPLHIV.

METHODS

We conducted a formative qualitative study in three health facilities in Kampala, Uganda, between July and August 2022. We held four focus group discussions with twenty-six YPLHIV seeking services at the study facilities. We also conducted six key informant interviews with health providers attached to adolescent HIV care clinics. Data was analyzed using thematic analysis guided by Sekhon's theoretical framework of acceptability (2017), which conceptualizes acceptability through multiple constructs, including affective attitudes, burden, intervention coherence, and perceived effectiveness. Our analysis examined these dimensions in the context of WhatsApp-based peer support groups for HIV care.

RESULTS

Overall, WhatsApp peer support groups were acceptable for use among YPLHIV. The young people regarded it as convenient because it would save time and would be more cost-effective compared to the transport costs of in-person meetings. Health providers revealed that the WhatsApp peer support group could reduce the stigma associated with community follow-up and empower YPLHIV to overcome stigma. Both young people and health providers suggested that online peer support could enhance emotional support, psychosocial well-being, and ART adherence. However, participants raised concerns about privacy and the cost of internet bundles and smartphones, especially for younger adolescents.

CONCLUSION

Online peer support groups are acceptable to Ugandan YPLHIV and hold promise in enhancing psychosocial support and improving treatment adherence in this sub-population. In implementing online support groups, due consideration should be given to software tools with high privacy standards and zero-rated data use for new apps. Research is needed to evaluate the feasibility and effectiveness of this peer support model in Uganda.

Evaluation of a Phone-Based Program to Increase Adherence to Antiretrovirals Among PLWH: A Pilot Study

Adherence to antiretroviral therapy (ART) is a major challenge for people living with HIV (PLWH). The purpose of this pilot study was to evaluate the six criteria for a phone-based intervention program for PLWH in Indonesia using a mixed methods feasibility study design. PLWH were included who took ART for at least 3 months, who had a cell phone, access to the internet, and the WhatsApp application. Thirty eligible respondents completed demographic information and shared their daily ART frequency during the enrolment visit. Motivational and health promotion messages were sent in the form of text message, images, and video links 30 min before their scheduled medication time for 3 months (October-December 2020). All respondents were retained until the end of the program. Necessity: Identified a need to be reminded when their ARTs were due. Feasibility: The participants were used to WhatsApp in their daily lives. Acceptability: The respondents responded well to the messages. Safety: None of the respondents experienced a mental distress due to involuntary HIV disclosure or stigma. Fidelity: The program delivered 79 to 91% of the messages. Challenges of the phone-based program centred around technical issues, human error user error, and environmental problems. Cost: The program could be delivered for less than $3 a day. The program met the six criteria for a useful intervention and can be applied to promote adherence to ART in remote regions of Indonesia.

Online Peer Support for Youth at Higher Risk of or Living with HIV: A Qualitative Content Analysis

With the rise of technology-based interventions for HIV risk reduction among adolescents, research is needed to assess how youth participate in these strategies. We used qualitative content analysis to examine youth's posts in an online peer support intervention through the Adolescent Trials Network (ClinicalTrials.gov NCT03134833, registered May 1, 2017) for youth at higher risk of or living with HIV. We analyzed 308 posts across 85 conversations related to sexual health from 144 peer support participants. Conversation topics included risk reduction, partner navigation, sexual activity, awareness/advocacy, and consent/harassment. Results may inform the design, adaptation, and implementation of digital peer support interventions.

Exploring the Use of Digital Educational Tools for Sexual and Reproductive Health in Sub-Saharan Africa: Systematic Review

BACKGROUND

Adolescents, particularly those in Sub-Saharan Africa, experience major challenges in getting accurate and comprehensive sexual and reproductive health (SRH) information because of sociocultural norms, stigma, and limited SRH educational resources. Digital educational tools, leveraging the widespread use of mobile phones and internet connectivity, present a promising avenue to overcome these barriers and enhance SRH education among adolescents in Sub-Saharan Africa.

OBJECTIVE

We conducted a systematic review to describe (1) the geographic and demographic distributions (designated objectives 1a and 1b, respectively, given their interrelatedness) and (2) the types and relevant impacts of digital educational tools (objective 2).

METHODS

We followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, using databases, such as Ovid-MEDLINE, Google Scholar, PubMed, and ERIC, to conduct literature searches. The selection criteria focused on studies that specifically addressed digital educational tools used to assess or deliver SRH education, their implementation, and their effectiveness among the adolescent population in Sub-Saharan Africa. We used the JBI critical appraisal tools for the quality assessment of papers included in the review.

RESULTS

The review identified 22 studies across Sub-Saharan Africa that met the inclusion criteria. The 22 studies spanned populations in West, Central, East, and South Africa, with an emphasis on youth and adolescents aged 10-24 years, reflecting the critical importance of reaching these age groups with effective, accessible, and engaging health education (objectives 1a and 1b). There was a diverse range of digital tools used, including social media platforms, mobile apps, and gamified learning experiences, for a broad age range of adolescent youth. These methods were generally successful in engaging adolescents by providing them with accessible and relevant SRH information (objective 2). However, challenges, such as the digital divide, the cultural sensitivity of the material, and the necessity for a thorough examination of the long-term influence of these tools on behavior modification, were noted.

CONCLUSIONS

Digital educational tools provide great potential to improve SRH education among adolescents in Sub-Saharan Africa. These technologies can help enhance relevant health outcomes and accessibility by delivering information that is easy to understand, interesting, and tailored to their needs. Future research should focus on addressing the identified challenges, including bridging the digital divide, ensuring cultural and contextual relevance of content, and assessing the long-term impact of digital SRH education on adolescent behavior and health outcomes. Policymakers and educators are encouraged to integrate digital tools into SRH educational strategies that target adolescents in order to improve the SRH of this age group and contribute to improving public health in Sub-Saharan Africa.

Implementing Task-Shared Child and Adolescent Psychological Interventions in Low- and Middle-Income Countries: A Scoping Review

OBJECTIVE

Effective "task shared," or nonspecialist delivered, psychological interventions for children and adolescents have been developed or adapted in low- and middle-income countries with the aim of closing the global treatment gap for youth mental health care. Yet, delivery remains limited, in part due to the lack of knowledge of associated implementation, or process, outcomes. This scoping review aims to describe, examine the quality of, and synthesize findings on implementation outcomes of child and adolescent psychological interventions in low-and middle-income countries.

METHODS

PubMed, Web of Science, and PsycInfo were searched for studies on child and adolescent psychological interventions in low- and middle-income countries reporting on implementation outcomes. After abstract and full-text review, data were extracted and summarized on implementation outcomes and quality of implementation outcomes reporting. Implementation barriers and recommendations for addressing barriers were also charted and narratively synthesized.

RESULTS

Out of 5,207 manuscripts, 86 met inclusion criteria. Younger children were underrepresented. Studies largely reported feasibility and acceptability and did not state hypotheses or use conceptual models. Barriers primarily related to interventions being too complex, not an acceptable fit with participant cultures, and facilitators lacking time for or experiencing distress delivering interventions. Recommendations focused on increasing intervention fit and flexibility, training and support for facilitators, and linkages with existing systems.

CONCLUSIONS

Rigorous, broader implementation outcomes research is needed within child and adolescent psychological intervention research in low-and middle-income countries. Current evidence suggests the importance of the further developing strategies to increase acceptability to participants and better support facilitators.

A Narrative-Gamified Mental Health App (Kuamsha) for Adolescents in Uganda: Mixed Methods Feasibility and Acceptability Study

BACKGROUND

Many adolescents in Uganda are affected by common mental disorders, but only a few affordable treatment options are available. Digital mental health interventions offer promising opportunities to reduce these large treatment gaps, but interventions specifically tailored for Ugandan adolescents are limited.

OBJECTIVE

This study aimed to determine the feasibility and acceptability of the Kuamsha program, an intervention delivered through a gamified app with low-intensity telephonic guidance, as a way to promote mental health among adolescents from the general population in Uganda.

METHODS

A 3-month pre-post single-arm trial was conducted with adolescents aged between 15 and 19 years living in Wakiso District, Central Uganda. The intervention was coproduced with adolescents from the study site to ensure that it was culturally acceptable. The feasibility and acceptability of the intervention were evaluated using an explanatory sequential mixed methods approach. Feasibility was assessed by collecting data on trial retention rates and treatment adherence rates. Acceptability was assessed through a questionnaire and in-depth interviews with participants following the conclusion of the intervention period. As a secondary objective, we explored the changes in participants' mental health before and after the intervention.

RESULTS

A total of 31 adolescents were recruited for the study. Results from the study showed high levels of feasibility and acceptability. Trial retention rates exceeded 90%, and treatment adherence was ≥80%. These results, evaluated against our predefined trial progression criteria, indicate a successful feasibility study, with all criteria exceeding the thresholds necessary to progress to a larger trial. App engagement metrics, such as time spent on the app and modules completed, exceeded existing literature benchmarks, and many adolescents continued to use the app after the intervention. In-depth interviews and questionnaire responses revealed high acceptability levels. Depressive symptoms trended toward reduction (mean difference: 1.41, 95% CI -0.60 to 3.42, Cohen d=0.30), although this was not statistically significant (P=.16). Supporting this trend, we also observed a reduction in the proportion of participants with moderate depressive symptoms from 32% (10/31) to 17% (5/29) after the intervention, but this change was also not significant (P=.10).

CONCLUSIONS

This study presents evidence to support the Kuamsha program as a feasible and acceptable digital mental health program for adolescents in Uganda. A fully powered randomized controlled trial is needed to assess its effectiveness in improving adolescents' mental health.

Digital technology for HIV self-management in low- and middle-income countries: a scoping review of adolescents' preferences

Digital health technology interventions have shown promise in enhancing self-management practices among adolescents living with Human Immunodeficiency Virus (ALHIV). The objective of this scoping review was to identify the preferences of ALHIV in low- and middle-income countries (LMICs) concerning the use of digital health technology for the self-management of their chronic illness. Electronic databases, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Plus with Full Text), Central (Cochrane Library), Epistemonikos, and Medline (EbscoHost), were searched. The review focused on English articles published before June 2023, that described a technology intervention for ALHIV specifically from LMIC. The screening and data extraction tool Covidence facilitated the scoping review process. Of the 413 studies identified, 10 were included in the review. Digital health technology interventions can offer enhanced support, education, and empowerment for ALHIV in LMICs. However, barriers like limited access, stigma, and privacy concerns must be addressed. Tailoring interventions to local contexts and integrating technology into healthcare systems can optimize their effectiveness.Review registration: OSF REGISTRIES (https://archive.org/details/osf-registrations-eh3jz-v1).

Acceptability of an online peer support group as a strategy to improve antiretroviral therapy adherence among young people in Kampala District, Uganda: qualitative findings

Introduction

Peer support groups may contribute to adherence and play a role in decreasing stigma to antiretroviral therapy (ART) adherence among young people living with HIV (YPLHIV). However, peer support activities usually occur face-to-face in Uganda and elsewhere in Sub-Saharan Africa, and thus have structural limitations and may not be readily available when young people need them. Online peer support has the potential to help YPLHIV access regular psychosocial support without significant effort or cost. We assessed the acceptability of a WhatsApp-based peer support group as a strategy to improve ART adherence among Ugandan YPLHIV.

Methods

We conducted a formative qualitative study in three health facilities in Kampala, Uganda, between July and August 2022. We held four focus group discussions with twenty-six YPLHIV seeking services at the study facilities. We also conducted six key informant interviews with health providers attached to adolescent HIV care clinics. The data was analyzed using thematic analysis guided by the acceptability framework to understand socio-cultural beliefs and perceptions towards utilizing WhatsApp-based peer support groups for HIV care.

Results

Overall, the peer support group on WhatsApp was acceptable for use among YPLHIV. The young people regarded it as convenient because it would save time and would be more cost-effective compared to the transport costs of in-person meetings. Health providers revealed that the WhatsApp peer support group could reduce the stigma associated with community follow-up for non-adhering young people and empower YPLHIV to overcome stigma. Both the young people and health providers suggested that online peer support could provide accessible emotional support, which could improve YPLHIV's psychosocial well-being and enhance adherence to ART. However, participants raised concerns about privacy, the cost of internet bundles, and smartphones, especially for younger adolescents.

Conclusion

Online peer support groups are acceptable to Ugandan YPLHIV and hold promise in enhancing psychosocial support and improving treatment adherence in this sub-population. In implementing online support groups, due consideration should be given to software tools with high privacy standards and zero-rated data use for new apps. Research is needed to evaluate the feasibility and effectiveness of this peer support model in Uganda.

Digital Mental Health Interventions for Adolescents in Low- and Middle-Income Countries: Scoping Review

BACKGROUND

Digital mental health interventions (DMHIs) are increasingly recognized as potential solutions for adolescent mental health, particularly in low- and middle-income countries (LMICs). The United Nations' Sustainable Development Goals and universal health coverage are instrumental tools for achieving mental health for all. Within this context, understanding the design, evaluation, as well as the barriers and facilitators impacting adolescent engagement with mental health care through DMHIs is essential.

OBJECTIVE

This scoping review aims to provide insights into the current landscape of DMHIs for adolescents in LMICs.

METHODS

The Joanna Briggs Institute scoping review methodology was used, following the recommendations of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). Our search strategy incorporated 3 key concepts: population "adolescents," concept "digital mental health interventions," and context "LMICs." We adapted this strategy for various databases, including ACM Digital Library, APA PsycINFO, Cochrane Library, Google Scholar (including gray literature), IEEE Xplore, ProQuest, PubMed (NLM), ScienceDirect, Scopus, and Web of Science. The articles were screened against a specific eligibility criterion from January 2019 to March 2024.

RESULTS

We analyzed 20 papers focusing on DMHIs for various mental health conditions among adolescents, such as depression, well-being, anxiety, stigma, self-harm, and suicide ideation. These interventions were delivered in diverse formats, including group delivery and self-guided interventions, with support from mental health professionals or involving lay professionals. The study designs and evaluation encompassed a range of methodologies, including randomized controlled trials, mixed methods studies, and feasibility studies.

CONCLUSIONS

While there have been notable advancements in DMHIs for adolescents in LMICs, the research base remains limited. Significant knowledge gaps persist regarding the long-term clinical benefits, the maturity and readiness of LMIC digital infrastructure, cultural appropriateness, and cost-effectiveness across the heterogeneous LMIC settings. Addressing these gaps necessitates large-scale, co-designed, and culturally sensitive DMHI trials. Future work should address this.

Prevalence of mental disorders among young people living with HIV: a systematic review and meta-analysis

Objective

This meta-analysis aims to evaluate the global prevalence of mental disorders among young people living with HIV.

Methods

A comprehensive search was conducted of the PubMed, Embase, and Cochrane Library databases for articles relevant to the study, published between January 2013 and June 2023. To identify sources of heterogeneity and compare prevalence estimates among various groups, subgroup analyses were conducted. Study heterogeneity was assessed using Cochran's Q and the I 2 tests. The robustness of the findings was ascertained through sensitivity analyses, while publication bias was evaluated with funnel plots and Egger's test.

Results

Sixty studies were included in this meta-analysis. It revealed that approximately one-quarter of YLWH experience depression, with a prevalence of 24.6% (95% CI: 21.1-28.2%). The prevalence of anxiety was found to be 17.0% (95% CI: 11.4-22.6%). Regarding suicidality, the prevalence of suicidal ideation and lifetime suicidal ideation in YLWH was 16.8% (95% CI: 11.3-22.4%) and 29.7% (95% CI: 23.7-35.7%), respectively. Additionally, the prevalence rates for suicidal attempts and lifetime suicidal attempts were 9.7% (95% CI: 4.0-15.4%) and 12.9% (95% CI: 2.8-23.1%), respectively. The prevalence of Post-Traumatic Stress Disorder and Attention Deficit Hyperactivity Disorder was identified as 10.5% (95% CI: 5.8-15.2%) and 5.0% (95% CI: 3.1-7.0%), respectively.

Conclusion

The findings indicate a heightened risk of mental disorders among YLWH, underscoring the necessity for targeted intervention strategies to mitigate their suffering and potentially diminish the adverse impacts.

Systematic Review Registration

PROSPERO, identifier CRD42023470050, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023470050.

"We did more than survive": lessons learned from studies of risk and resilience of young people growing up with HIV and mental health needs

Despite advances in HIV-treatment, adolescents and young adults (AYA) with HIV (AYAHIV) face myriad challenges. They are less likely than children and older adults to be virally suppressed and are at higher risk for mental health conditions compared to their peers who do not have HIV. AYA are also developing in the context of numerous biomedical, neurocognitive, and psychosocial developmental changes. Normative challenges during this time can be exacerbated by HIV and can result in significant physical and mental health problems. Yet, many AYAHIV have shown resilience with positive assets and resources and few health or mental health problems. Historically research has had a risk-focused approach to understanding AYAHIV needs. This paper discusses the rationale for a shift from a risk-focused only approach to one that examines AYAHIV needs from both a risk and resilience perspective. This paper presents: (1) epidemiological data on AYAHIV; (2) conceptual models for understanding both risk (e.g., poverty, stress, trauma, limited resources) and resilience/protective factors (e.g., family and peer support, future orientation, problem-solving skills); (3) global data examining risk and protective factors for physical and mental health challenges; and (4) promising interventions that incorporate elements of resilience to improve overall outcomes among AYAHIV.

An mHealth Intervention to Address Depression and Improve Antiretroviral Therapy Adherence Among Youths Living With HIV in Uganda: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

People living with HIV often struggle with mental health comorbidities that lower their antiretroviral therapy (ART) adherence. There is growing evidence that depression treatment may improve ART adherence and result in improved HIV outcomes. Given that mental health services are severely underequipped in low-resource settings, including in Uganda, new solutions to increase access to mental health care and close the treatment gap are urgently needed. This protocol paper presents the Suubi-Mhealth study, which proposed to develop a mobile health (mHealth) intervention for use among Ugandan youths (14-17 years) with comorbid HIV and depression, taking into account their unique contextual, cultural, and developmental needs.

OBJECTIVE

The proposed study is guided by the following objectives: (1) to develop and iteratively refine an intervention protocol for Suubi-Mhealth based on formative work to understand the needs of youths living with HIV; (2) to explore the feasibility and acceptability of Suubi-Mhealth on a small scale to inform subsequent refinement; (3) to test the preliminary impact of Suubi-Mhealth versus a waitlist control group on youths' outcomes, including depression and treatment adherence; and (4) to examine barriers and facilitators for integrating Suubi-Mhealth into health care settings.

METHODS

Youths will be eligible to participate in the study if they are (1) 14-17 years of age, (2) HIV-positive and aware of their status, (3) receiving care and ART from one of the participating clinics, and (4) living within a family. The study will be conducted in 2 phases. In phase 1, we will conduct focus group discussions with youths and health care providers, for feedback on the proposed intervention content and methods, and explore the feasibility and acceptability of the intervention. In phase II, we will pilot-test the preliminary impact of the intervention on reducing depression and improving ART adherence. Assessments will be conducted at baseline, 1-, 2-, and 6-months post intervention completion.

RESULTS

Participant recruitment for phase 1 is completed. Youths and health care providers participated in focus group discussions to share their feedback on the proposed Suubi-Mhealth intervention content, methods, design, and format. Transcription and translation of focus group discussions have been completed. The team is currently developing Suubi-Mhealth content based on participants' feedback.

CONCLUSIONS

This study will lay important groundwork for several initiatives at the intersection of digital therapeutics, HIV treatment, and mental health, especially among sub-Saharan African youths, as they transition through adolescence and into adult HIV care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05965245; https://clinicaltrials.gov/study/NCT05965245.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54635.

Implementation outcomes in psychosocial intervention studies for children and adolescents living in low- and middle-income countries: A systematic review

Psychosocial interventions play a key role in addressing mental health and substance use needs for children and adolescents living in low- and middle-income countries (LMICs). While research efforts have primarily focused on their effectiveness, implementation outcomes also require examining. We conducted a systematic review of qualitative, quantitative, and mixed-methods studies (PROSPERO: CRD42022335997) to synthesize the literature on implementation outcomes for psychosocial interventions for children and adolescents in LMICs. We searched Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Web of Science, PsychINFO, and Global Health through April 2023. Data were extracted and quality appraised through the Mixed Methods Appraisal Tool (MMAT) independently by two reviewers. A total of 13,380 records were screened, and 87 studies met inclusion criteria. Feasibility was the most reported implementation outcome (69, 79%), followed by acceptability (60, 69%), and fidelity (32, 37%). Appropriateness was assessed in 11 studies (13%), implementation costs in 10 (11%), and sustainability in one (1%). None of the included studies reported on penetration or adoption. Despite a growing body of evidence for implementation research in child and adolescent global mental health, most research focused on earlier-stage implementation outcomes, assessing them in research-controlled settings. To overcome this, future efforts should focus on assessing interventions in routine care, assessing later-stage implementation outcomes through standardized tools.

A randomized controlled trial of the dissemination of an mHealth intervention for improving health outcomes: the WiseApp for Spanish-speakers living with HIV study protocol

BACKGROUND

While there is no cure for HIV, adherence to antiretroviral therapy can extend the lifespan and improve the quality of life of people with HIV. Despite the global reduction of HIV infection rates in recent years, New York City and La Romana, Dominican Republic, continue to report high infection rates among Latino populations. Many people with HIV remain virally unsuppressed in these geographic hotspots, suggesting a need for additional interventions to overcome medication adherence barriers. Tailored and culturally appropriate mobile health (mHealth) technology can be an engaging way to improve adherence. The primary objective of this trial is to test the effectiveness of an mHealth tool to improve HIV medication adherence among Spanish-speaking people living in New York City and the Dominican Republic.

METHODS

The WiseApp study is a two-arm randomized controlled trial among 248 people with HIV across the New York and Dominican Republic sites over the course of 12 months. Participants are randomly assigned to either receive a CleverCap pill bottle that is linked to the WiseApp (intervention) or standard of care (control). All participants complete surveys at baseline, 3-month, 6-month, and 12-month follow-up visits and the study team obtains HIV-1 viral load and CD4 count results through blood draw at each study timepoint.

DISCUSSION

The use of mHealth technologies to improve medication adherence among people with HIV has been implemented in recent years. Although some studies have found improvement in adherence to antiretroviral therapy in the short term, there is limited information about how these interventions improve adherence among Spanish-speaking populations. Disproportionate rates of HIV infection among Latinos in New York City suggest an existing inequitable approach in reaching and treating this population. Due to a lack of mHealth studies with Latino populations, and apps tailored to Spanish-speakers, the WiseApp study will not only demonstrate the effectiveness of this particular mHealth app but will also contribute to the mHealth research community as a whole.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (NCT05398185) on 5/31/2022.

Facilitated WhatsApp Support Groups for Youth Living With HIV in Nairobi, Kenya: Single-Arm Pilot Intervention Study

BACKGROUND

Mobile technology can support HIV care, but studies in youth are limited. In 2014, youth receiving HIV care at several health care facilities in Nairobi, Kenya spontaneously formed peer support groups using the social media platform WhatsApp.

OBJECTIVE

Inspired by youth-initiated groups, we aimed to evaluate the use of WhatsApp to deliver a social support intervention to improve HIV treatment and psychosocial outcomes in youth. We developed a facilitated WhatsApp group intervention (named Vijana-SMART), which was grounded in social support theory and guided by the design recommendations of youth living with HIV. This paper evaluates the intervention's acceptability and pre-post changes in health outcomes.

METHODS

The intervention involved interactive WhatsApp groups facilitated by study staff for 6 months, with each group having approximately 25 members. Study staff sent weekly structured messages, and the message content was based on social support theory and encouraged unstructured peer-to-peer messaging and support. We conducted a single-arm pilot among 55 youth living with HIV aged 14-24 years recruited from a government health care facility serving a mixed-income area of Nairobi. At enrollment and follow-up, self-report questionnaires assessed acceptability; antiretroviral therapy (ART) information, motivation, and behavioral skills (IMB); depression; social support; stigma; resilience; and ART adherence. All participants received the intervention. We used generalized estimating equations (GEEs) clustered by participant to evaluate changes in scores from baseline to follow-up, and correlates of participant WhatsApp messaging.

RESULTS

The median participant age was 18 years, and 67% (37/55) were female. Intervention acceptability was high. All participants reported that it was helpful, and 73% (38/52) sent ≥1 WhatsApp message. Messaging levels varied considerably between participants and were higher during school holidays, earlier in the intervention period, and among youth aged ≥18 years. IMB scores increased from enrollment to follow-up (66.9% to 71.3%; P<.001). Stigma scores also increased (8.3% to 16.7%; P=.001), and resilience scores decreased (75.0% to 70.0%; P<.001). We found no significant change in ART adherence, social support, or depression. We detected a positive association between the level of messaging during the study and the resilience score, but no significant association between messaging and other outcomes. Once enrolled, it was common for participants to change their phone numbers or leave the groups and request to be added back, which may present implementation challenges at a larger scale.

CONCLUSIONS

Increased IMB scores following WhatsApp group participation may improve HIV outcomes. Increased stigma and decreased resilience were unintended consequences and may reflect transient effects of group sharing of challenging experiences, which should be addressed in larger randomized evaluations. WhatsApp groups present a promising and acceptable modality to deliver supportive interventions to youth living with HIV beyond the clinic, and further evaluation is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05634265); https://clinicaltrials.gov/study/NCT05634265.

Promotive and preventive interventions for adolescent mental health in Sub-Saharan Africa: a combined scoping and systematic review

Introduction

Poor mental health in adolescence is associated with mental, physical and social problems in later life. Adolescence is, therefore, a critical time for promoting mental well-being and preventing mental illness, particularly in sub-Saharan Africa, where adolescents are exposed to a multitude of risk factors for poor mental health. This review aimed to map the current use, effectiveness and cultural sensitivity of promotive/preventive adolescent mental health interventions in the region.

Methods

A combined scoping and systematic review was conducted using the Arksey and O'Malley framework through searches in MEDLINE, CINAHL, Global Health, PsycINFO and the Cochrane Database of Systematic Reviews, covering January 2000 to December 2021.

Results

This review identified 79 papers, related to 61 unique interventions. Only five universal, school-based programmes were identified; most studies targeted orphans or HIV positive adolescents. Psychosocial interventions-aimed at strengthening knowledge, expression and psychosocial skills-produced mixed results. Structural interventions were often community-based and had limited psychosocial programming. Those that focused on HIV prevention, gender equity and parenting also produced mixed results; evidence was strongest for economic-livelihood programmes. Few studies described cultural sensitivity in detail. Some explained how the intervention aligned with local worldviews/values; had context-specific content; were based on explorations of relevant concepts; or integrated spiritual/cultural practices.

Conclusion

Preventive/promotive interventions for adolescent mental health in sub-Saharan Africa are limited in terms of geographical spread, but broad in terms of intervention types. Targeted approaches reflect realities that adolescents in the region face in relation to socioeconomic deprivation, family disruption and poor physical health. Yet, universal interventions that focus on general well-being are limited and lack a consideration of contemporary developments in the region such as increased social media use, suicide and obesity. Economic livelihood interventions showed most consistent evidence of effectiveness. Future studies could do more to consider/report cultural sensitivity.

Feasibility of Lantern Using WhatsApp to Improve Antiretroviral Therapy Adherence

This pilot study tested the feasibility of Lantern program, an adherence program to HIV medications using WhatsApp, a secure social media messaging application from Meta, for a smartphone-based platform to enhance medication-taking adherence of antiretroviral therapy among people living with HIV in Indonesia. Thirty participants were recruited for this 8-week study. We recruited persons if they had taken antiretroviral therapy for at least 3 months prior to the study, had a smartphone, Internet access, and could use Lantern with WhatsApp. Here, we report the results from the focus group discussions, with the participants evaluating the qualitative aspects of the experiences. The WhatsApp platform was found to be safe, practical, and relatively inexpensive and provided confidentiality for the participants. Three themes emerged from the focus groups: the study motivated participants to take their antiretroviral therapy medications on time, they still set medication reminder alarms, and being in the study made them feel supported. The Lantern program indicated good feasibility and acceptability for adherence to antiretroviral therapies among people living with HIV. Future research should examine on how community organizations and healthcare providers can take advantage of the WhatsApp program to improve adherence to antiretroviral therapies.

A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa

Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.

Characterizing provider-led adaptations to mobile phone delivery of the Adolescent Transition Package (ATP) in Kenya using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS): a mixed methods approach

BACKGROUND

The COVID-19 pandemic resulted in disruptions to routine HIV services for youth living with HIV (YLH), provoking rapid adaptation to mitigate interruptions in care. The Adolescent Transition to Adult Care for HIV-infected adolescents (ATTACH) study (NCT03574129) was a hybrid I cluster randomized trial testing the effectiveness of a healthcare worker (HCW)-delivered disclosure and transition intervention - the Adolescent Transition Package (ATP). During the pandemic, HCWs leveraged phone delivery of the ATP and were supported to make adaptations. We characterized real-time, provider-driven adaptations made to support phone delivery of the ATP.

METHODS

We conducted continuous quality improvement (CQI) meetings with HCWs involved in phone delivery of the ATP at 10 intervention sites. CQI meetings used plan-do-study-act (PDSA) cycles and were audio-recorded. Adaptations were coded by two-independent coders using the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS). Adaptation testing outcomes (adopt, retest, or abandon) and provider experience implementing the adaptations were also recorded. We summarized adaptation characteristics, provider experience, and outcomes.

RESULTS

We identified 72 adaptations, 32 were unique. Overall, adaptations included modification to context (53%, n = 38), content (49%, n = 35), and evaluation processes (13%, n = 9). Context adaptations primarily featured changes to personnel, format, and setting, while content and evaluation adaptations were frequently achieved by simple additions, repetition, and tailoring/refining of the phone delivery strategy. Nine adaptations involved abandoning, then returning to phone delivery. HCWs sought to increase reach, improve fidelity, and intervention fit within their context. Most adaptations (96%, n = 69) were perceived to increase the feasibility of phone delivery when compared to before the changes were introduced, and HCWs felt 83% (n = 60) of adaptations made phone delivery easier. Most adaptations were either incorporated into routine workflows (47%) or tested again (47%).

CONCLUSION

Adaptation of phone delivery was a feasible and effective way of addressing challenges with continuity of care for YLH during the COVID-19 pandemic. Adaptations were primarily context adaptions. While FRAME-IS was apt for characterizing adaptations, more use cases are needed to explore the range of its utility.

TRIAL REGISTRATION

Trial registered on ClinicalTrial.gov as NCT03574129.

Interventions to Improve Adolescent HIV Care Outcomes

PURPOSE OF REVIEW

This review of recent studies evaluating interventions to improve HIV care outcomes among adolescents with HIV (AHIV) was conducted to provide a comprehensive overview of the recent evidence, highlight promising approaches, and suggest directions for future research.

RECENT FINDINGS

Our scoping review revealed 65 studies evaluating a variety of interventions and using a range of study designs at various stages of research. Effective approaches included community-based, integrated service delivery models with case management, trained community adolescent treatment supporters, and consideration of social determinants of health. Recent evidence also supports the feasibility, acceptability, and preliminary efficacy of other innovative approaches, including mental health interventions as well as technology-delivered approaches; however, more research is needed to build the evidence base for these interventions. Our review's findings suggest that interventions providing comprehensive, individualized support are essential to improving HIV care outcomes among adolescents. More research is needed to build the evidence base for such interventions and ensure effective, equitable implementation to support the global target of ending the AIDS epidemic by 2030.

Feasibility and Acceptability of the Adherence Connection Counseling, Education, and Support (ACCESS) Proof of Concept: A Peer-Led, Mobile Health (mHealth) Cognitive Behavioral Antiretroviral Therapy (ART) Adherence Intervention for HIV-Infected (HIV+) Adolescents and Young Adults (AYA)

Effective antiretroviral therapy (ART) adherence strategies for HIV+ adolescents and young adults (AYA) are needed to prevent HIV-related morbidity, mortality, and onward transmission. In the Adherence Connection for Counseling, Education, and Support (ACCESS) pilot, an exploratory sequential mixed-methods design was used to develop and test a peer-led, mobile health (mHealth) cognitive behavioral ART adherence intervention. HIV+ AYA (ages 16-29 years) with unsuppressed plasma HIV RNA (HIV viral load) were eligible for this five-session intervention directed to improving ART adherence and HIV viral load. A total of 78 peer-led remote videoconferencing sessions (via WebEx) were delivered to 16 participants. High completion rates (97.5%) and client satisfaction scores (mean = 29.13 of 32; SD = 2.45) were observed. Self-reported ART adherence improved (32% increase in doses taken; 95th CI 11.2-53.3) with an annualized average rate of 47.5% (0.28 log10) reduction in HIV viral load. We established proof of concept for the ACCESS peer-led, mHealth cognitive behavioral ART adherence intervention, with promising adherence and virologic outcome data.

Implementation Science for the Prevention and Treatment of HIV among Adolescents and Young Adults in Sub-Saharan Africa: A Scoping Review

Despite many evidence-based adolescent and young adult (AYA) HIV interventions, few are implemented at scale in sub-Saharan Africa (SSA). A growing implementation science literature provides important context for scaling up AYA HIV interventions in this high HIV-burden region. This scoping review examined the use of implementation research in AYA HIV studies conducted in SSA. We searched five databases and included articles which focused on AYA (10-24 years old), addressed HIV prevention or treatment, were conducted exclusively in SSA countries, and included an implementation science outcome. We included 44 articles in 13 SSA countries. Most were in East (52.3%) and South Africa (27.3%), and half focused exclusively on HIV prevention components of the care continuum. Acceptability and feasibility were the most cited implementation science outcomes. Only four articles used an established implementation science framework. The findings informed our recommendations to guide the design, implementation, and dissemination of further studies and health policymaking.

Integrating Adolescent Mental Health into HIV Prevention and Treatment Programs: Can Implementation Science Pave the Path Forward?

Adolescent mental health (AMH) is a critical driver of HIV outcomes, but is often overlooked in HIV research and programming. The implementation science Exploration, Preparation, Implementation, Sustainment (EPIS) framework informed development of a questionnaire that was sent to a global alliance of adolescent HIV researchers, providers, and implementors working in sub-Saharan Africa with the aim to (1) describe current AMH outcomes incorporated into HIV research within the alliance; (2) identify determinants (barriers/gaps) of integrating AMH into HIV research and care; and (3) describe current AMH screening and referral systems in adolescent HIV programs in sub-Saharan Africa. Respondents reported on fourteen named studies that included AMH outcomes in HIV research. Barriers to AMH integration in HIV research and care programs were explored with suggested implementation science strategies to achieve the goal of integrated and sustained mental health services within adolescent HIV programs.

Effects of mobile technology-based interventions for promoting mental health and psychosocial well-being among young people in low- and middle-income countries: a systematic review protocol

OBJECTIVE

This review will aim to examine the effectiveness of mobile-based technologies among young people (10 to 24 years) in low- and middle-income countries to promote their mental health and psychosocial well-being. Such interventions may be in the form of mobile technology-based education, information, or psychosocial counseling.

INTRODUCTION

Young people in low- and middle-income countries have limited access to mental health services. Mobile-based technologies, such as remote consultations, telehealth, and smartphone applications, can improve access to mental health services; however, to the best of our knowledge, there are no systematic reviews of effectiveness on this topic.

INCLUSION CRITERIA

This review will consider evidence from low- and middle-income countries on mobile-based technologies for mental health and psychosocial support interventions for young people. All experimental and observational studies published in English from 2010 to 2022 will be included.

METHODS

The review will follow the JBI methodology for systematic reviews of effectiveness. Embase (Ovid), CINAHL (EBSCO), PsycINFO (ProQuest), AMED (Ovid), HMIC (Ovid) MEDLINE (PubMed), and Web of Science will be searched. Gray literature will be identified through Directory of Open Access Journals, ProQuest Dissertations and Theses, EThOs, Asia eHealth Information Network, Google Scholar, and Grey Literature Report. Retrieved articles will be screened against the inclusion criteria, and then assessed by 2 independent reviewers for methodological quality using standardized JBI appraisal tools. Data will be extracted using standardized JBI data extraction tools. Narrative synthesis will be preferred if meta-analysis is not feasible, while certainty of evidence will be assessed using the GRADE approach.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022338749.

Effectiveness, Acceptability and Feasibility of Technology-Enabled Health Interventions for Adolescents Living with HIV in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Adolescents living with HIV (ALHIV) are challenged to remain adherent and engaged in HIV care. Technology-enabled interventions can be used to optimize healthcare delivery to adolescents. The largest proportion of ALHIV resides in sub-Saharan Africa. This review synthesized the evidence for the effectiveness, acceptability, and feasibility of technology-enabled health interventions for ALHIV in low and middle-income countries (LMIC).

METHODS

Eight electronic databases (Ebscohost, CINAHL, ERIC, MEDLINE, PubMed, SCOPUS, Science Direct, and Sabinet) and Google Scholar were searched to identify studies in LMIC published from 2010 to 2022. Quantitative and qualitative studies reporting on technology-enabled health interventions for predominantly adolescents (10-19 years) were included. The review was performed, and findings were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols. The review was registered with PROSPERO: CRD42022336330.

RESULTS

There is weak evidence that technology-enabled health interventions for ALHIV in LMIC improve treatment outcomes. However, most interventions appear to be acceptable and feasible.

CONCLUSION

There is a need to ensure that technology-enabled interventions have a strong theoretical base. Larger studies with rigorous evaluation designs are needed to determine the effects of these interventions on the health outcomes of ALHIV in LMIC.

Effectiveness of mHealth on Adherence to Antiretroviral Therapy in Patients Living With HIV: Meta-analysis of Randomized Controlled Trials

BACKGROUND

The World Health Organization recommends that all adults with HIV adhere to antiretroviral therapy (ART). Good adherence to ART is beneficial to patients and the public. Furthermore, mHealth has shown promise in improving HIV medication adherence globally.

OBJECTIVE

The aim of this meta-analysis is to analyze the effectiveness of mHealth on adherence to antiretroviral therapy in patients living with HIV.

METHODS

Randomized controlled trials (RCTs) of the association between mHealth and adherence to ART published until December 2021 were searched in electronic databases. Odds ratios (ORs), weighted mean differences, and 95% CIs were calculated. This meta-analysis was performed using the Mantel-Haenszel method or the inverse variance test. We evaluated heterogeneity with the I2 statistic. If I2 was ≤50%, heterogeneity was absent, and a fixed effect model was used. If I2 was >50%, heterogeneity was present, and a random effects model was used.

RESULTS

A total of 2163 participants in 8 studies were included in this meta-analysis. All included studies were RCTs. The random effects model was used for a meta-analysis of the effects of various intervention measures compared to routine nursing; the outcome was not statistically significant (OR 1.54, 95% CI 0.99-2.38; P=.05). In the subgroups, only short messaging service (SMS)-based interventions significantly increased adherence to ART (OR 1.76, 95% CI 1.07-2.89; P=.03). Further analysis showed that only interactive or bidirectional SMS could significantly increase ART adherence (OR 1.69, 95% CI 1.22-2.34; P=.001). After combining the difference in CD4 cell count before and after the interventions, we concluded that there was no statistical heterogeneity among the studies (I2=0%; tau2=0.37; P=.95).

CONCLUSIONS

Interactive or bidirectional SMS can enhance intervention effects. However, whether mHealth can improve adherence to ART in patients with HIV needs further study. Owing to a lack of the required significant staff time, training, and ongoing supervision, there is still much more to do to apply mHealth to the clinical use of ART for patients living with HIV.

TRIAL REGISTRATION

PROSPERO CRD42022358774; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=358774.

Barriers and facilitators to anti-retroviral therapy adherence among adolescents aged 10 to 19 years living with HIV in sub-Saharan Africa: A mixed-methods systematic review and meta-analysis

BACKGROUND

Human Immunodeficiency Virus (HIV) significantly affects adolescents globally, with the sub-Saharan Africa (SSA) reporting a high burden of the disease. HIV testing, treatment, and retention to care are low among adolescents. We conducted a mixed-method systematic review to assess anti-retroviral therapy (ART) adherence; barriers and facilitators to ART adherence and ART outcomes among adolescents living with HIV and on ART in sub-Saharan Africa.

METHODS

We conducted searches in four scientific databases for studies conducted between 2010 and March 2022 to identify relevant primary studies. Studies were screened against inclusion criteria and assessed for quality, and data was extracted. Meta-analysis of rates and odd ratios was used to plot the quantitative studies and meta-synthesis summarized the evidence from qualitative studies.

RESULTS

A total of 10 431 studies were identified and screened against the inclusion/ exclusion criteria. Sixty-six studies met the inclusion criteria (41 quantitative, 16 qualitative, and 9 mixed-methods study designs). Fifty-three thousand two hundred and seventeen (53 217) adolescents (52 319 in quantitative studies and 899 in qualitative studies) were included in the review. Thirteen support focused interventions for improved ART adherence were identified from quantitative studies. The plotted results from the meta-analysis found an ART adherence rate of 65% (95%CI 56-74), viral load suppression was 55% (95%CI 46-64), un-suppressed viral load rate of 41% (95%CI 32-50), and loss to follow up of 17% (95%CI 10-24) among adolescents. Meta-synthesis found six themes of barriers to ART (social, patient-based, economic, health system-based, therapy-based, and cultural barriers) in both the qualitative and quantitative studies, and three themes of facilitators to ART were also identified (social support, counselling, and ART education and secrecy or confidentiality) from qualitative studies.

CONCLUSION

ART adherence remains low among adolescents in SSA despite multiple interventions implemented to improve ART adherence. The low adherence rate may hinder the attainment of the UNAIDS 2030 targets. Additionally, various barriers to ART adherence due to lack of support have been reported among this age group. However, interventions aimed at improving social support, educating, and counselling adolescents may improve and sustain ART adherence.

TRIAL REGISTRATION

Systematic review registration: PROSPERO CRD42021284891.

Telehealth Interventions for HIV in Low- and Middle-Income Countries

PURPOSE OF REVIEW

This review summarizes technology-based interventions for HIV in low- and middle-income countries (LMICs). We highlight potential benefits and challenges to using telehealth in LMICs and propose areas for future study.

RECENT FINDINGS

We identified several models for using telehealth to expand HIV health care access in LMICs, including telemedicine visits for pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART) services, telementoring programs for providers, and virtual peer-support groups. Emerging data support the acceptability and feasibility of these strategies. However, further investigations are needed to determine whether these models are scalable and sustainable in the face of barriers related to cost, infrastructure, and regulatory approval. HIV telehealth interventions may be a valuable approach to addressing gaps along the HIV care cascade in LMICs. Future studies should focus on strategies for expanding existing programs to scale and for assessing long-term clinical outcomes.

Rethinking mental health wellness among adolescents living with HIV in the African context: An integrative review of mental wellness components

Objective

Adolescents living with HIV (ALHIV) are considered to be at heightened risk for developing mental health problems in comparison to their peers due to the burden of living with a stigmatized condition and managing a chronic condition. Poorer mental health outcomes among ALHIV are associated with lower rates of adherence to anti-retroviral therapy (ART). It is necessary to improve mental wellness among ALHIV as this acts as a buffer against developing mental health problems which, if left untreated can evolve into mental health disorders. Research on mental wellness concepts among ALHIV is underdeveloped which is associated with a lack of appropriate measures of mental wellness. We conducted an integrative review to conceptualize mental wellness and consider the critical components for measuring mental wellness in ALHIV.

Method

An integrative review of published literature focusing on mental wellness of ALHIV in the African context was conducted. The process was guided by the PRISMA operational steps. As part of our problem identification phase, we drew on findings from a previous systematic review of mental wellness instruments and a qualitative photovoice study on exploring the experiences of ALHIV, to develop an initial framework of 13 mental wellness concepts and behaviors which informed the search strategy.

Results

The review included 17 articles from which we identified six mental wellness concepts: Connectedness, Sense of Coherence (SOC), Self-esteem, Self-acceptance, Hope for the Future and Spirituality as well as six behaviors facilitating mental wellness: Coping, Resilience, Purpose in Life (goals), Self-efficacy, Adherence Self-efficacy, and Leisure Activities. All of these concepts and behaviors have been noted in our previous research (systematic review and qualitative work), with the exception of adherence self-efficacy. Based on the findings from this review and our previous work, we adapted the Salutogenic Model of Health developed by Antonovsky in 1987, to propose a Salutogenic Model of Mental Wellness (SMoMW) for ALHIV in the African context. This SMoMW may be used to develop an age and culturally appropriate measure of mental wellness for ALHIV.

Conclusion

The findings from this review used to conceptualize mental wellness among ALHIV which can be used to develop a measurement of mental wellness.

Internet-based peer support interventions for people living with HIV: A scoping review

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.

Mental health interventions for adolescents in sub-Saharan Africa: A scoping review

Background

Globally, adolescents are vulnerable to mental health problems, particularly those from sub-Saharan Africa (SSA) due to impoverished living conditions and a higher prevalence of chronic conditions such as HIV/AIDS in the region. The COVID-19 pandemic has further exacerbated this risk. This calls for an urgent need for evidence-based adolescent mental health interventions to reduce the risk and burden of mental health problems in SSA. The review aims to identify and characterize existing adolescent mental health interventions in SSA, as well as to evaluate their implementation strategies and effectiveness.

Methods

We systematically searched PubMed, African Index Medicus, PsycINFO, Web of Science, and CINAHL databases for relevant articles. Furthermore, we searched gray literature databases, including Think Tank search, open gray, NGO search engine, and IGO search engine for additional relevant articles. The scoping review was conducted to identify original research articles on mental health interventions among adolescents in sub-Saharan Africa published from database inception to 31 December 2021. We carried out a narrative synthesis to report our findings.

Results

Our literature search generated 4,750 studies, of which 1,141 were duplicates, 3,545 were excluded after screening, and 64 articles met the inclusion criteria. The 64 studies describe a total of 57 unique mental health interventions comprising 40,072 adolescents. The nature of these interventions was diverse, encompassing various implementation strategies such as economic-based, family strengthening, psychoeducation, interpersonal psychotherapy, Cognitive Behavioral Therapy, and resilience training, among others. Most of the interventions were selective interventions that targeted adolescents at high risk of developing mental health problems including adolescents living with HIV, war-affected adolescents, orphans, adolescents from poorer backgrounds, and survivors of sexual violence. Half of the interventions were delivered by lay persons. Sixty-two of the eligible studies examined the effectiveness of the mental health interventions, of which 55 of them reported a positive significant impact on various mental health outcomes.

Conclusions

The review findings show that there exist several diverse interventions that promote mental health among adolescents in sub-Saharan Africa. These interventions can be implemented in diverse settings including schools, communities, health facilities, and camps, and can be delivered by lay persons.

Voices from the Youth in Kenya Addressing Mental Health Gaps and Recommendations

Studies including adolescents and young people (AYP) enhance the relevance of research results, benefit stakeholders, and inform future research. There exists a mental health gap in services for AYP living in low and middle-income countries. This study aims to identify mental health challenges faced by adolescents and young people in Kenya, develop practical recommendations to mitigate these issues, and reduce the mental health burden among this population. We convened an AYP-led meeting that involved 41 participants. The meeting objectives were to (1) identify efforts to support existing national and regional strategic priorities and review goals for addressing mental health needs among AYPs, (2) develop immediate action plans for strengthened mental health services, (3) review and strengthen country-level coordination mechanisms, and (4) identify how participating county experiences can inform mental health services in Kenya. Ministry of Health (MoH) officials from national and county levels, academic experts, and implementing partner agencies involved in mental health services participated in the meeting. The team, including AYP representatives, identified various mental health challenges among the AYA and recommended interventions aimed towards improving their mental health situation in the country. The challenges were clustered into three themes and comprehensively reviewed to establish the precipitating factors to mental health outcomes among AYPs in Kenya and provide recommendations. The themes included (1) legislative, (2) service provider/Ministry of Health, and (3) adolescent/individual-level factors. To bridge the mental health gap in the country and scale up mental health outcomes, the stakeholders recommended interventions within the context of the three clusters. The key suggestions included an increase in insurance financing, acceleration of community health interventions, the establishment of adolescent-friendly spaces, the training of adolescent youth champions, interactive service provision models, implementation of the existing mental health policies and structures, the development of comprehensive assessment tools, well equipped mental health departments in health facilities, the enhancement of telehealth services and digital villages, the mobilization of a functional mental health response team, and the development of a mental health database.

Social, economic, and health effects of the COVID-19 pandemic on adolescents retained in or recently disengaged from HIV care in Kenya

INTRODUCTION

Adolescents living with HIV (ALHIV, ages 10-19) experience complex challenges to adhere to antiretroviral therapy (ART) and remain in care, and may be vulnerable to wide-scale disruptions during the COVID-19 pandemic. We assessed for a range of effects of the pandemic on ALHIV in western Kenya, and whether effects were greater for ALHIV with recent histories of being lost to program (LTP).

METHODS

ALHIV were recruited from an ongoing prospective study at 3 sites in western Kenya. The parent study enrolled participants from February 2019-September 2020, into groups of ALHIV either 1) retained in care or 2) LTP and traced in the community. Phone interviews from July 2020-January 2021 assessed effects of the pandemic on financial and food security, healthcare access and behaviors, and mental health. Responses were compared among the parent study groups.

RESULTS

Phone surveys were completed with 334 ALHIV or their caregivers, including 275/308 (89.3%) in the retained group and 59/70 (84.3%) among those LTP at initial enrollment. During the pandemic, a greater proportion of LTP adolescents were no longer engaged in school (45.8% vs. 36.4%, p = 0.017). Over a third (120, 35.9%) of adolescents reported lost income for someone they relied on. In total, 135 (40.4%) did not have enough food either some (121, 36.2%) or most (14, 4.2%) of the time. More LTP adolescents (4/59, 6.8% vs. 2/275, 0.7%, p = 0.010) reported increased difficulties refilling ART. Adolescent PHQ-2 and GAD-2 scores were ≥3 for 5.6% and 5.2%, respectively.

CONCLUSIONS

The COVID-19 pandemic has had devastating socioeconomic effects for Kenyan ALHIV and their households. ALHIV with recent care disengagement may be especially vulnerable. Meanwhile, sustained ART access and adherence potentially signal resilience and strengths of ALHIV and their care programs. Findings from this survey indicate the critical need for support to ALHIV during this crisis.