Depression and anxiety as barriers to art initiation, retention in care, and treatment outcomes in KwaZulu-Natal, South Africa

Immunological and Neurological Signatures of the Co-Infection of HIV and HTLV: Current Insights and Future Perspectives

The human retroviruses HIV and HTLV-1/HTLV-2 are transmitted through similar pathways but result in markedly different diseases. This review delineates the immune-mediated mechanisms by which HTLVs influence HIV pathology in co-infected individuals. In the context of HIV co-infection, HTLV-1/HTLV-2 alter the cellular microenvironment to enhance their own survival while simultaneously impeding the progression of HIV. Despite the extensive body of literature on the biological and clinical implications of retroviral co-infections, decades of research have been marred by controversy due to several flawed epidemiological studies and anecdotal reports lacking robust statistical and scientific backing. Nevertheless, recent systematic and well-designed research has led to a growing consensus supporting at least three key conclusions: (1) co-infections of HIV-1 and HTLV-1 are frequently observed in patients with elevated CD4+ T-cell counts who present with lymphoma or neurological complications; (2) HIV-1 and HTLV-2 co-infections have been associated in some instances with a "long-term non-progressor" phenotype; (3) the differential function and/or overexpression of the HTLV-1 and HTLV-2 Tax proteins are likely crucial in the clinical and immunologic outcomes of HIV/HTLV-1 and -2 co-infections. The present review will provide a comprehensive account of research on retroviral co-infections, focusing particularly on their clinical manifestations and associated pathological features.

Prevalence of significant anxiety symptoms and associated factors among adult people with HIV/AIDS in care and treatment clinic centers in Kilimanjaro region, Tanzania: a cross-sectional study

BACKGROUND

People with human immunodeficiency virus (PWH) are more prone to generalized anxiety disorder. There is a limited understanding of the prevalence of significant anxiety symptoms and its associated risk factors among adult PWH in the Tanzanian context. This study aims to determine the prevalence of significant anxiety symptoms and related risk factors among adult PWH attending care and treatment clinics in Moshi Municipality, Kilimanjaro Region.

METHODS

We used a multistage random cluster sampling approach to select participants at four Care and treatment centers (CTCs) of Kilimanjaro Christian Medical Centre, Mawenzi Regional Referral Hospital, Majengo, and Pasua Health Centre, by location at tertiary, secondary, and primary health care levels. The seven-item Generalized Anxiety Disorder (GAD-7) screening tool assessed levels of generalized anxiety symptoms with significance set at scores ≥ 10. Sociodemographic, clinical, and psychosocial characteristics were collected using a semi-structured questionnaire. Bivariate analyses determined factors associated with significant anxiety symptoms (GAD-7 ≥ 10) at p-values [Formula: see text]0.20 for inclusion in the multivariate model. Adjusted prevalence ratios with confidence intervals are reported with significance set at a p-value of < 0.05.

RESULTS

Out of 593 PWH participants, 12.48% screened positive for significant anxiety symptoms. Participants treated at the tertiary health facility level (aPR = 2.91, 95% CI: 2.48-3.41, P-value = 0.001), early adulthood 25-44 years (aPR = 1.75, 95% CI: 1.27-2.42, P-value = 0.001), with higher anxiety sensitivity (aPR = 3.28, 95% CI: 2.08-5.19, P-value = 0.001), and higher levels of perceived social support (aPR = 2.09; 95% CI: 1.34-3.27, P-value = 0.001) showed a higher likelihood of significant generalized anxiety symptoms.

CONCLUSIONS

Significant anxiety symptoms were common among adult PWH. Integrating routine generalized anxiety screening and raising PWH's and primary caregivers' awareness of GAD is recommended.

TRIAL REGISTRATION

Clinical trial number not applicable.

Siyakhana: A hybrid type 2 effectiveness-implementation stepped-wedge trial to reduce stigma towards substance use and depression among community health workers in HIV/TB care in South Africa

INTRODUCTION

Substance use (SU) and other mental health conditions, such as depression, contribute to poor engagement in HIV and TB care in South Africa, a country with the highest global prevalence of HIV and a significant TB burden. Yet, community health workers (CHWs)-frontline lay health workers who play a central role in re-engaging patients in HIV/TB care-receive little-to-no training on supporting patients with SU or other mental health concerns. CHWs also display stigma towards patients with SU and depression, which may contribute to HIV/TB care disengagement. We developed and tested a CHW training ("Siyakhana") to reduce CHW stigma towards SU and depression in HIV/TB care.

METHODS

A cluster randomized, stepped-wedge hybrid type 2 effectiveness-implementation trial (N = 82 CHWs) evaluated Siyakhana across six clinics in a low-resource area of Cape Town, SA. The three-day Siyakhana training included psychoeducation, self-care strategies, non-judgmental communication, problem solving, and contact-based stigma reduction using lived experience narratives. Pre-training and three- and six-month post-training assessments were conducted. Primary effectiveness outcomes were CHW stigma towards SU and depression, assessed using the Social Distance Scale. Primary implementation outcomes were guided by Proctor's model, including fidelity, acceptability, appropriateness, and feasibility, assessed using structured coding of role plays and a validated quantitative measure for assessing implementation outcomes in low- and middle-income countries.

RESULTS

Participants were on average 46.8 years old (SD = 8.9), 99% female, and 100% Black African. Ninety-five percent of CHWs completed the Siyakhana training, with approximately 90% retention over six months. A linear mixed effects model showed a significant effect of the Siyakhana training on reducing SU stigma over six months after adjusting for time (β = -1.46, SE = 0.67, p < 0.05), but no effect on depression stigma (β = -0.20, SE = 0.57, p > 0.05). CHW fidelity was 89.4% (SD = 11.3%) at six-months. Quantitative implementation outcomes indicated high acceptability (M = 2.85, SD = 0.27), appropriateness (M = 2.77, SD = 0.31), and feasibility (M = 2.41, SD = 0.38).

CONCLUSIONS

Siyakhana was associated with reductions in CHW SU stigma in the context of HIV/TB care, with promising implementation outcomes. Findings will inform a larger randomized trial evaluating the effectiveness and implementation of Siyakhana and examine whether shifting CHW stigma improves patient-level health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT05282173. Registered on 7 March 2022.

Hospitalized with HIV in Zambia: individual and system factors driving the high burden of admissions and post-discharge mortality in the era of HIV epidemic control

BACKGROUND

Despite progress towards HIV epidemic control, people living with HIV (PLHIV) in Zambia continue to face high mortality during and especially after hospitalization, with suboptimal post-discharge care leading to poor outcomes. We conducted a qualitative study to better understand factors influencing post-discharge engagement in care for HIV and associated comorbidities.

METHODS

We conducted in-depth interviews with 16 recently discharged PLHIV, seven caregivers, and two doctors; and three focus group discussions with inpatient doctors (n = 8) and lay counsellors (n = 16) at two tertiary hospitals in Lusaka, guided by the social-ecological model. Data were audio-recorded, transcribed verbatim, managed with Atlas.ti 9, and thematically analyzed.

RESULTS

Individual and household-level barriers to post-discharge care for PLHIV included HIV status denial and stigma, limited disclosure, and limited social and emotional support. Health-related barriers included concomitant treatments for TB, HIV comorbidities, and behavioral health issues like depression and alcohol abuse. Health system barriers included limited confidentiality during admission and poor communication between healthcare providers and between facilities aftercare transitions following discharge. Social-economic factors included economic shocks of hospitalization and post-discharge recovery, which compounded pre-existing poverty and high transportation and food costs. Conversely, disclosure of HIV status, better social support, a financially stable household, and hospital follow-up appointment reminders facilitated better post-discharge care.

CONCLUSION

After hospital discharge with HIV, system and individual challenges exacerbate pre-existing interpersonal, health, environmental, and system-related factors to cause poor outcomes. Holistic community-based interventions to facilitate these patients' re-engagement in care after discharge could help HIV programs reach the last mile in epidemic control.

The relationships between perceived parental rearing, social support, PTSD, and depression in people living with HIV in China: a cross-sectional study

Post-traumatic stress disorder (PTSD) and depression are two major psychological disorders that affect the mental health of people living with HIV (PLWH). The occurrence of PTSD and depression may be linked to perceptions of parental rearing styles in childhood. However, little is known about the relationship between perceived parental rearing styles, and PTSD and depression in the PLWH population. This study investigated 300 PLWH and explored the relationship between perceived parental rearing style, social support, PTSD, and depression. The results indicated that perceived paternal and maternal warmth were negatively associated with PTSD. Perceived maternal warmth and overprotection were negatively associated with depression. Social support acted as a mediator between perceived parental warmth, PTSD, and depression. Therefore, it is necessary to focus on patients who feel they experienced a lack of parental warmth during childhood and provide psychological care and support, which may help reduce the risk of developing PTSD and depression.

Depressive symptoms and HIV among a cohort of adolescent young men and transgender women who have sex with men, Bangkok and Nakhon Sawan, Thailand, 2017-2019

Screening for depression may identify persons for HIV prevention services and to ensure linkage to care for ART and mental health. We assessed factors associated with depressive symptoms using multiple logistic regression among 15- to 29-year-old gay, bisexual or other men who have sex with men (MSM) and transgender women who have sex with men (TGW) attending HIV prevention clinics at Silom Community Clinic or Bangrak Hospital in Bangkok or Rainbow Clinic in Nakhon Sawan, Thailand. We defined depressive symptoms as a self-report of feelings of sadness that impacted daily life in the past one month. Among 192 MSM, 51 TGW, and 11 gender-questioning persons screened: 12.6% met the criteria for depression; 5.9% had new HIV diagnosis. Independently associated factors which increase the risk of depressive symptoms included: studying in a private school (AOR 7.17); experiencing any type of bullying (AOR 2.8); having a partner with HIV (AOR 4.1); and learning about the study from sources other than a friend (AOR 4.2). Given many youths had depressive symptoms, screening for depression and connection to mental health services would be beneficial in sexual health settings to meet the needs of HIV-vulnerable youth.

Nurse-led sequential multiple assignment randomized trial of nudging intervention for early antiretroviral therapy initiation among patients with HIV/AIDS: Implementation study protocol

AIMS

In China, more than 30% of patients have not initiated treatment within 30 days of HIV diagnosis. Delayed initiation has a detrimental influence on disease outcomes and increases HIV transmission. The study aims to evaluate the effectiveness of a nurse-led antiretroviral therapy initiation nudging intervention for people newly diagnosed with HIV in China to find the optimal intervention implementation strategy.

METHODS

A Hybrid Type II sequential multiple assignment randomized trial will be conducted at four Centers for Disease Control and Prevention in Hunan, China. This study will recruit 447 people newly diagnosed with HIV aged ≥18 years and randomly assign them into two intervention groups and one control group. On top of the regular counselling services and referrals, intervention groups will receive a 4-week, 2-phase intervention based on the dual-system theory and the nudge theory. The control group will follow the currently recommended referral procedures. The primary outcomes are whether treatment is initiated, as well as the length of time it takes. The study outcomes will be measured at the baseline, day 15, day 30, week 12, week 24 and week 48. Generalized estimating equations and survival analysis will be used to compare effectiveness and explore factors associated with antiretroviral therapy initiation. Both qualitative and quantitative information will be collected to assess implementation outcomes.

DISCUSSION

Existing strategies mostly target institutional-level factors, with little consideration given to patients' decision-making. To close this gap, we aim to develop an effective theory-driven nudging strategy to improve early ART initiation.

IMPACT

This nurse-led study will help to prevent delayed initiation by employing implementation science strategies for people newly diagnosed with HIV. This study contributes to the United Nations' objective of ending the AIDS pandemic by 2030.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2300070140. The trial was prospectively registered before the first participant was recruited.

PATIENT AND PUBLIC INVOLVEMENT

The nudging intervention was finalized through the Nominal Group Technique where we invited five experts in the related field and five people living with HIV to participate.

Interaction of social support and depressive symptoms on antiretroviral therapy adherence among people living with HIV in South Africa

Background

Depression consistently emerges as a significant predictor of poor antiretroviral therapy (ART) adherence among adult people living with human immunodeficiency virus (PLHIV). However, a gap exists regarding how social support and depressive symptoms can interact to influence ART adherence among adult PLHIV in South Africa (SA).

Aim

To investigate the interaction between social support and depressive symptoms on ART adherence among adult PLHIV.

Setting

A tertiary hospital in Durban, KwaZulu-Natal province of SA.

Methods

Utilising a quantitative cross-sectional research design along with time location sampling technique (TLS); the study recruited 201 adult patients enrolled in an ART programme.

Results

The results indicated that depressive symptoms were significantly associated with ART adherence with and without the interaction (B = -0.105; odds ratios [OR] 0.901; 95% confidence intervals [CI] = 0.827, 0.981; p = 0.016), while social support was not significantly associated with ART adherence (B = 0.007; OR 1.007; 95%CI = 0.989, 1.025; p = 0.475). However, a statistically significant interaction was found between social support and depressive symptoms (B = -0.006; OR 0.994; 95%CI = 0.989, 1.000; p = 0.037) on ART adherence.

Conclusion

Based on the results, depressive symptoms significantly influenced ART adherence. However, social support did not buffer the adverse effects of clinical depression associated with poor ART adherence.

Contribution

This study provides an evidence-based approach to address gaps in the mental health and social well-being of PLHIV in the context of ART adherence.

Community health worker training to reduce mental health and substance use stigma towards patients who have disengaged from HIV/TB care in South Africa: protocol for a stepped wedge hybrid type II pilot implementation trial

BACKGROUND

South Africa has deployed community health workers (CHWs) to support individuals to enter and stay in HIV/TB care. Although CHWs routinely encounter patients with mental health (particularly depression) and substance use (SU) conditions that impact their engagement in HIV/TB care, CHWs are rarely trained in how to work with these patients. This contributes to mental health and SU stigma among CHWs, a known barrier to patient engagement in care. Mental health and SU training interventions could reduce CHW stigma and potentially improve patient engagement in care, but evidence of the feasibility, acceptability, and preliminary effectiveness of these interventions is scarce. Therefore, we designed a hybrid type 2 effectiveness-implementation pilot trial to evaluate the implementation and preliminary effectiveness of a CHW training intervention for reducing depression and SU stigma in the Western Cape, South Africa.

METHODS

This stepped wedge pilot trial will engage CHWs from six primary care clinics offering HIV/TB care. Clinics will be block randomized into three-step cohorts that receive the intervention at varying time points. The Siyakhana intervention involves 3 days of training in depression and SU focused on psychoeducation, evidence-based skills for working with patients, and self-care strategies for promoting CHW wellness. The implementation strategy involves social contact with people with lived experience of depression/SU during training (via patient videos and a peer trainer) and clinical supervision to support CHWs to practice new skills. Both implementation outcomes (acceptability, feasibility, fidelity) and preliminary effectiveness of the intervention on CHW stigma will be assessed using mixed methods at 3- and 6-month follow-up assessments.

DISCUSSION

This trial will advance knowledge of the feasibility, acceptability, and preliminary effectiveness of a CHW training for reducing depression and SU stigma towards patients with HIV and/or TB. Study findings will inform a larger implementation trial to evaluate the longer-term implementation and effectiveness of this intervention for reducing CHW stigma towards patients with depression and SU and improving patient engagement in HIV/TB care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05282173. Registered on 7 March 2022.

Correlates of Depression in ART Adherence among Youths in Lilongwe, Malawi

Despite collaborative efforts to improve mental health services among youths living with HIV (YLHIVs) aged 15-24, evidence shows that many suffer from depression. We established the correlates of depression and how it affects ART adherence. Structured questionnaires, a Patient Health Questionnaire 9 depression scale assessment, in-depth interviews, and Electronic Medical Record reviews were conducted at the Lighthouse Trust Martin Preus Centre (MPC) ART clinic in Lilongwe from April 2021 to October 2022. A total of 303 YLHIVs aged 15-24 were on ART, and 7 key informants were recruited. Bivariate and multivariate logistic regression analyses were performed using STATA V14.1. A thematic content analysis was used for qualitative data. Forty-six per cent of recruits were male, and fifty-four per cent were female. Seventy-one per cent were aged 20-24, and twenty-nine per cent were aged 15-19. Twenty-three per cent of the YLHIVs had depression symptoms, of whom seventy-nine per cent were aged 20-24 years. Twenty-two per cent had an unsuppressed viral load (non-adherent). Sixty-seven per cent of non-adherent participants were aged 20-24. There was no factor associated with ART non-adherence. Source of income (p = 0.003), alcohol consumption (p = 0.010), and sexual behaviour (p = 0.014) were associated with depression. Sexual behaviour was statistically significantly associated with depression (p = 0.024. The themes were a lack of basic needs, a lack of privacy, psychological trauma, incomplete disclosure, a shortage of psychosocial providers, and a knowledge deficit of ART providers to screen for depression. This study shows that depression is considerably high among YLHIVs in Malawi and linked to ART non-adherence. Strengthening mental health training for providers and routinely screening YLHIVs for depression would help in the early identification and management of depression, thereby improving ART adherence.

Depressive Symptoms among People Living with HIV Attending ART Centers of Lumbini Province, Nepal: A Cross-Sectional Study

Background

Depression is a common mental disorder and is a leading cause of disability globally. Depressive symptoms among people living with HIV can be a significant barrier to ART initiation and thus lead to poor ART adherence. Global studies have found the prevalence of depressive symptoms among people living with HIV ranges from 12 to 63%. The real scenario of Nepal still needs to be explored. Thus, this study aimed to identify the prevalence and predictors of depression in individuals with HIV.

Methods

An institutional-based cross-sectional study was carried out from August to December 2020 among 406 people living with HIV attending ART centers in Lumbini province. Participants were selected using a systematic random sampling technique and surveyed with a structured questionnaire consisting of sociodemographic variables, HIV AIDS-related variables, and 21 items Beck Depression Inventory tool. The odds ratio was used as the ultimate measure of association, with a 95% confidence interval computed to establish statistical significance. A multivariate regression analysis was carried out to identify the final predictors of depressive symptoms.

Results

The study found that 26.8% of the respondents had depressive symptoms. Those who were literate (AOR = 0.24, 95% CI: 0.10-0.61), in the poorest wealth quintile (AOR = 7.28, 95% CI: 2.22-23.87), initiated ART within 12 months (AOR = 1.88, 95% CI: 1.03-3.42), had CD4 cell counts below 200 (AOR = 2.50, 95% CI: 1.54-4.06), and had a time difference of 3 months or less between HIV diagnosis and ART initiation (AOR = 0.50, 95% CI: 0.29-0.86) were independently associated with depressive symptoms.

Conclusion

Routine screening for depressive symptoms should be integrated into national HIV prevention and control programs for people living with HIV. An enabling environment should be created to facilitate the rapid enrollment of individuals newly diagnosed with HIV in ART services, thereby reducing the time gap between HIV diagnosis and ART initiation.

Tools for Screening and Measuring Anxiety Among Women Living with HIV of Reproductive Age: A Scoping Review

Emerging evidence suggests that women living with HIV (WLWH) may experience higher rates of anxiety than men living with HIV and women living without HIV. To date, relatively little knowledge exists on valid anxiety screening and diagnostic tools and how they are used among WLWH, specifically WLWH of reproductive age. Thus, the purpose of this scoping review was to describe what is known in the published literature about anxiety among WLWH and the tools used to measure and screen for anxiety in clinical and research contexts. The Arksey and O'Malley methodological framework was used to guide a scoping review of published articles in PsycINFO, Scopus, Sociological Abstracts, and PubMed databases. Twenty-one measures of anxiety were used across the 52 articles identified in the search. Most measures used were self-report. Inconsistencies in standardized screening tools and cutoff scores were observed across studies. Further, measures to assess anxiety varied among studies focused on WLWH. Based on the results from this review, there is a need for consistent, valid measures of anxiety to advance research and clinical practice to support the well-being of WLWH.

The Clinical Impact and Cost-Effectiveness of Clinic-Based Cognitive Behavioral Therapy for People With HIV, Depression, and Virologic Failure in South Africa

BACKGROUND

Depression affects 25%-30% of people with HIV (PWH) in the Republic of South Africa (RSA) and is associated with both antiretroviral therapy (ART) nonadherence and increased mortality. We evaluated the cost-effectiveness of task-shifted, cognitive behavioral therapy (CBT) for PWH with diagnosed depression and virologic failure from a randomized trial in RSA.

SETTING

RSA.

METHODS

Using the Cost-Effectiveness of Preventing AIDS Complications model, we simulated both trial strategies: enhanced treatment as usual (ETAU) and ETAU plus CBT for ART adherence and depression (CBT-AD; 8 sessions plus 2 follow-ups). In the trial, viral suppression at 1 year was 20% with ETAU and 32% with CBT-AD. Model inputs included mean initial age (39 years) and CD4 count (214/μL), ART costs ($7.5-22/mo), and CBT costs ($29/session). We projected 5- and 10-year viral suppression, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs: $/QALY [discounted 3%/yr]; cost-effectiveness threshold: ≤$2545/QALY [0.5× per capita GDP]). In sensitivity analyses, we determined how input parameter variation affected cost-effectiveness.

RESULTS

Model-projected 5- and 10-year viral suppression were 18.9% and 8.7% with ETAU and 21.2% and 9.7% with CBT-AD, respectively. Compared with ETAU, CBT-AD would increase discounted life expectancy from 4.12 to 4.68 QALYs and costs from $6210/person to $6670/person (incremental cost-effectiveness ratio: $840/QALY). CBT-AD would remain cost-effective unless CBT-AD cost >$70/session and simultaneously improved 1-year viral suppression by ≤4% compared with ETAU.

CONCLUSIONS

CBT for PWH with depression and virologic failure in RSA could improve life expectancy and be cost-effective. Such targeted mental health interventions should be integrated into HIV care.

Availability of screening and treatment for common mental disorders in HIV clinic settings: data from the global International epidemiology Databases to Evaluate AIDS (IeDEA) Consortium, 2016-2017 and 2020

INTRODUCTION

Common mental disorders (CMDs) are highly prevalent among people with HIV. Integrating mental healthcare into HIV care may improve mental health and HIV treatment outcomes. We describe the reported availability of screening and treatment for depression, anxiety and post-traumatic stress disorder (PTSD) at global HIV treatment centres participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) Consortium in 2020 and changes in availability at sites in low- or middle-income countries (LMICs) between 2016/2017 and 2020.

METHODS

In 2020, 238 sites contributing individual-level data to the IeDEA Consortium and in 2016/2017 a stratified random sample of IeDEA sites in LMICs were eligible to participate in site surveys on the availability of screening and treatment for CMDs. We assessed trends over time for 68 sites across 27 LMICs that participated in both surveys.

RESULTS

Among the 238 sites eligible to participate in the 2020 site survey, 227 (95%) participated, and mental health screening and treatment data were available for 223 (98%) sites across 41 countries. A total of 95 sites across 29 LMICs completed the 2016/2017 survey. In 2020, 68% of sites were in urban settings, and 77% were in LMICs. Overall, 50%, 14% and 12% of sites reported screening with a validated instrument for depression, anxiety and PTSD, respectively. Screening plus treatment in the form of counselling was available for depression, anxiety and PTSD at 46%, 13% and 11% of sites, respectively. Screening plus treatment in the form of medication was available for depression, anxiety and PTSD at 36%, 11% and 8% of sites, respectively. Among sites that participated in both surveys, screening for depression was more commonly available in 2020 than 2016/2017 (75% vs. 59%, respectively, p = 0.048).

CONCLUSIONS

Reported availability of screening for depression increased among this group of IeDEA sites in LMICs between 2016/2017 and 2020. However, substantial gaps persist in the availability of mental healthcare at HIV treatment sites across global settings, particularly in resource-constrained settings. Implementation of sustainable strategies to integrate mental health services into HIV care is needed.

Low antiretroviral therapy uptake and low early retention among pregnant women who tested positive for human immunodeficiency virus in informal health centers in urban and semi-rural settings in Cameroon: a prospective cohort study

Introduction

Despite the efforts of Cameroon's Ministry of Public Health against informal health centers (IHCs) because of their illegitimacy, the number of IHCs is increasing in Cameroon. Most of these IHCs have antenatal care services and screen pregnant women for HIV. However, nothing is known about the subsequent outcomes of those who tested positive for HIV. This study aimed to assess the initiation of antiretroviral therapy (ART) in ART-naïve pregnant women screened HIV positive in IHCs within three months of diagnosis and their ART retention at three months post-initiation. In addition, we sought to identify the factors associated with ART non-initiation in this population.

Methods

May 01, 2019 to August 31, 2020, we carried out a prospective cohort study of ART-naïve pregnant women who attended their first antenatal care visit and screened HIV positive at IHCs in the cities of Douala and Ebolowa in Cameroon. Standardized questionnaires were used to interview consenting participants at three points: the day of the delivery of the antenatal HIV test result, three months later, and three months after ART initiation. The data collected were entered into KoboCollect and analyzed using SPSS V23.0 software. The Chi-square test was used to compare proportions, Kaplan Meier techniques and Cox proportional hazards regression was used to estimate retention in ART and identify factors associated with ART non-retention, respectively.

Results and discussion

A total of 85 ART-naïve pregnant women living with HIV were enrolled in the study. The median age and gestational age at the first antenatal care visit were 29 years (interquartile range (IQR), 2333.5) and 28weeks of amenorrhea (IQR, 2032), respectively. Only 34% (29/85) initiated ART, and 65.5% (19/29) of the initiators were retained in ART three months later. Lack of perceived self-efficacy to initiate ART (adjust Hazard Ratio = 5.57, 90% CI: 1.29 to 24.06), increased the probability of not be retaining in ART by any time during three months post initiation. Given the low ART uptake and the low retention in care among pregnant women living with HIV screened in IHCs, PMTCT policies in Cameroon should pay greater attention to this population, to facilitate their continuum of PMTCT care.

Association between mental disorders and adherence to antiretroviral treatment in health facilities in two Mozambican provinces in 2018: a cross-sectional study

INTRODUCTION

Lower adherence to antiretroviral treatment (ART) has been found among people with HIV (PWH) who have comorbid mental disorders like depression and alcohol use in Sub-Saharan African. However, there has been less exploration with regards to other mental disorders.

METHODS

This study assessed the association of multiple mental disorders and adherence to ART based on the data from primary/tertiary health care facilities in Maputo and Nampula, Mozambique. We administered a sociodemographic questionnaire, Mini International Neuropsychiatric Interview (MINI) Plus 4.0.0 adapted for use in Mozambique to assess mental conditions, and a 3-item self-report to measure ART adherence.

RESULTS

395 HIV-positive (self-report) participants on ART, with an average age of 36.7 years (SD = 9.8), and 30.4% were male. The most common mental disorders were major depressive disorder (27.34%) followed by psychosis (22.03%), suicidal ideation/behavior (15.44%), and alcohol-use disorder (8.35%). Higher odds of missing at least one dose in the last 30 days (OR = 1.45, 95% CI: 1.01, 2.10) were found in participants with any mental disorder compared to those without a mental disorder. The highest levels of non-adherence were observed among those with drug use disorders and panic disorder.

CONCLUSIONS

In Mozambique, PWH with any co-occurring mental conditions had a lower probability of ART adherence. Integrating comprehensive mental health assessment and treatment and ART adherence interventions tailored to PWH with co-occurring mental disorders is necessary to attain optimal ART adherence and reach the UNAIDS ART target.

Peer-Led Community-Based Support Services and HIV Treatment Outcomes Among People Living With HIV in Wuxi, China: Propensity Score-Matched Analysis of Surveillance Data From 2006 to 2021

BACKGROUND

Community-based organizations deliver peer-led support services to people living with HIV. Systematic reviews have found that peer-led community-based support services can improve HIV treatment outcomes; however, few studies have been implemented to evaluate its impact on mortality using long-term follow-up data.

OBJECTIVE

We aimed to evaluate the associations between the receipt of peer-led community-based support services and HIV treatment outcomes and survival among people living with HIV in Wuxi, China.

METHODS

We performed a propensity score-matched retrospective cohort study using data collected from the Chinese National HIV/AIDS Comprehensive Information Management System for people living with HIV in Wuxi, China, between 2006 and 2021. People living with HIV who received adjunctive peer-led community-based support for at least 6 months from a local community-based organization (exposure group) were matched to people living with HIV who only received routine clinic-based HIV care (control group). We compared the differences in HIV treatment outcomes and survival between these 2 groups using Kaplan-Meier curves. We used competing risk and Cox proportional hazards models to assess correlates of AIDS-related mortality (ARM) and all-cause mortality. We reported adjusted subdistribution hazard ratio and adjusted hazard ratio with 95% CIs.

RESULTS

A total of 860 people living with HIV were included (430 in the exposure group and 430 in the control group). The exposure group was more likely to adhere to antiretroviral therapy (ART; 396/430, 92.1% vs 360/430, 83.7%; P<.001), remain retained in care 12 months after ART initiation (402/430, 93.5% vs 327/430, 76.1%; P<.001), and achieve viral suppression 9 to 24 months after ART initiation (357/381, 93.7% vs 217/243, 89.3%; P=.048) than the control group. The exposure group had significantly lower ARM (1.8 vs 7.0 per 1000 person-years; P=.01) and all-cause mortality (2.3 vs 9.3 per 1000 person-years; P=.002) and significantly higher cumulative survival rates (P=.003). The exposure group had a 72% reduction in ARM (adjusted subdistribution hazard ratio 0.28, 95% CI 0.09-0.95) and a 70% reduction in all-cause mortality (adjusted hazard ratio 0.30, 95% CI 0.11-0.82). The nonrandomized retrospective nature of our analysis prevents us from determining whether peer-led community-based support caused the observed differences in HIV treatment outcomes and survival between the exposure and control groups.

CONCLUSIONS

The receipt of peer-led community-based support services correlated with significantly improved HIV treatment outcomes and survival among people living with HIV in a middle-income country in Asia. The 15-year follow-up period in this study allowed us to identify associations with survival not previously reported in the literature. Future interventional trials are needed to confirm these findings.

Dolutegravir in real life: Self-reported mental and physical health outcomes after transitioning from efavirenz- to dolutegravir-based antiretroviral therapy in a prospective cohort study in Lesotho

INTRODUCTION

HIV programmes across many countries in Africa have recently transitioned people living with HIV from efavirenz (EFV)- to dolutegravir (DTG)-containing antiretroviral therapy (ART). As both drugs are associated with neuropsychiatric adverse effects, this study assessed the mental health and HIV/ART-associated symptoms of people living with HIV before and after transition to DTG.

METHODS

The prospective DO-REAL cohort enrolled people starting DTG-based ART in Lesotho from February to December 2020. For this analysis within DO-REAL, we included adults changing from tenofovir disoproxil fumarate (TDF)/lamivudine (3TC)/EFV to TDF/3TC/DTG within first-line therapy. At transition and 16 weeks thereafter, participants completed the Patient Health Questionnaire-9 (PHQ-9; depression screening), the 12-item Short-Form Health Survey (SF-12; mental and physical health), and a modified HIV Symptom Index (mHSI; HIV/ART-related symptoms). We also assessed weight change. We used McNemar tests with Bonferroni corrections to assess binary outcomes.

CLINICALTRIALS

gov: NCT04238767.

RESULTS

Among 1228 participants, 1131 completed follow-up. Of these, 60.0% were female, the median age was 46 years (interquartile range [IQR] 38-55), and the median time taking ART was 5.7 years (IQR 3.5-8.9). No change was observed for weight or overall PHQ-9 or SF-12 outcomes. However, three mHSI items decreased at follow-up: 'feeling sad/down/depressed' (bothered 6.0% vs. 3.3% of participants at least 'a little' before vs. after transition; adjusted p = 0.048); 'feeling nervous/anxious' (7.4% vs. 3.4%; adjusted p = 0.0009); and 'nightmares, strange/vivid dreams' (6.3% vs. 3.5%; adjusted p = 0.027). Individual PHQ-9 or SF-12 items also improved. Being symptom free across all measures increased from 5.1% to 11.4% (p < 0.0001).

CONCLUSIONS

We observed no negative impacts and potential moderate improvements with DTG, providing further support for the rollout of DTG.

Differences in Reasons for Late Presentation to HIV Care in Uganda Among Men and Women

Late presentation to HIV care, i.e., presenting with < 200 CD4 cells/mL, is associated with higher mortality and worse outcomes. Despite that, a quarter of people living with HIV in Uganda still present late to care. We surveyed Ugandans living with HIV who enrolled in clinic ≤ 90 days prior. We compared groups who presented 'late' with CD4 < 200 and 'early' with CD4 > 350, stratifying by sex. We found men who presented late had higher externalized stigma than early presenters. Thirty-six percent of the entire cohort were depressed. Social support was stronger in late presenters versus early, although weak overall. Social support was inversely correlated with depression, with social support dropping as depression increased. Interventions to improve clinic privacy, reduce stigma, improve social support, and help women disclose their HIV status to male partners are needed to reduce late presentation to HIV care.

Persistent depressive disorder among persons receiving an HIV test: an understudied phenomenon

Persistent depressive disorder is under-studied in HIV settings. We recruited 500 persons seeking an HIV test in South Africa and administered the major depression and persistent depression modules of the Structured Clinical Interview for the DSM-5, the Beck Depression Inventory (BDI), Beck Anxiety Inventory, Alcohol Use and Drug Use Disorders Identification Tests and the PTSD Symptom Scale. Of the total sample, 7.2% met the criteria for persistent depression and 14.4% had major depression; 3.6% had both Major Depression and Persistent Depression; 3.6% had Persistent Depression and no Major Depression; 10.8% had Major Depression and no Persistent Depression; and 82.0% had neither Major Depression nor Persistent Depression. We found a significant relationship between major and persistent depression (X² (1, N = 500) = 39.89; p < .00; 95% CI). Persons with PDD were over 7 times more likely to have major depression than those without PDD (OR = 7.59; 95% CI: 3.72-15.48). Income level and BDI scores were significant predictors of persistent depression (p < 0.05), but not anxiety, traumatisation, and harmful alcohol and drug use. Many people may experience diagnosable mood disturbance prior to receipt of their HIV test results, suggesting the need to integrate mental health services with HIV testing.

Mental health and initiation of antiretroviral treatment at enrolment into HIV care in Cameroon under a national "treat all" policy: a cross-sectional analysis

Introduction

Rapid antiretroviral treatment (ART) initiation reduces time from HIV infection to viral suppression, decreasing HIV transmission risk. Mental health symptoms may influence timing of ART initiation. This study estimated the prevalence of ART initiation at enrolment into HIV care and the relationship between mental health and ART initiation at enrolment into HIV care.

Methods

We conducted interviews with 426 individuals initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the association between mental health and timing of ART initiation. Depression (Patient Health Questionnaire‐9; cut‐point 10), anxiety (Generalized Anxiety Disorder‐7; cut‐point 10), post‐traumatic stress disorder (PTSD) (PTSD Checklist for DSM‐5; cut‐point 31) and harmful alcohol use (Alcohol Use Disorders Identification Test; cut‐point 16) were dichotomized to represent those with and without each exposure at first HIV care appointment. Date of ART initiation (date ART prescribed) was ascertained from medical records. Separate multivariable log‐binomial regression models were used to estimate the association between mental health exposures and ART initiation at enrolment into care.

Results and discussion

Overall, 87% initiated ART at enrolment into HIV care. Approximately 20% reported depressive symptoms, 15% reported PTSD symptoms, 12% reported anxiety symptoms and 13% reported harmful alcohol use. In multivariable analyses, individuals with moderate to severe depressive symptoms had 1.7 (95% confidence interval [CI] 1.1, 2.7) times the prevalence of not initiating ART at enrolment into HIV care compared to those with no or mild depressive symptoms. Those with symptoms of PTSD, compared to those without, had 1.9 (95% CI 1.2, 2.9) times the prevalence of not initiating ART at enrolment into HIV care. Symptoms of anxiety or harmful drinking were not associated with ART initiation at enrolment into HIV care in multivariable models.

Conclusions

Symptoms of depression and PTSD were associated with lower prevalence of ART initiation at enrolment into HIV care among this sample of individuals initiating HIV care in Cameroon under a “treat all” policy. Research should examine barriers to timely ART initiation, whether incorporating mental health services into HIV care improves timely ART initiation, and whether untreated symptoms of depression and PTSD drive suboptimal HIV care outcomes.

Improving Detection of Depression in People Living with HIV: Psychometric Properties of the South African Depression Scale (SADS)

Most measures developed in high income countries to screen for major depressive disorder (MDD) among people living with HIV (PWH) demonstrate suboptimal psychometric properties when utilized in non-western, resource limited settings due to their high false positive rates. For standardized MDD screening to be implementable in local settings, a measure is needed that reduces diagnostic burden by being highly sensitive while limiting false positives. This study sought to evaluate the ability of the locally developed South African Depression Scale (SADS) to screen for MDD in PWH in Cape Town. The SADS was administered along with the SCID-5-RV as gold standard to 236 PWH. It demonstrated good discriminating ability in detecting MDD with an area under the curve of 0.85. A cut-off of 27 yielded 78.2% sensitivity and 54.4% PPV. Given its robust psychometric properties, routine use of the SADS in community clinics to screen at-risk PWH, combined with evidence-based depression treatment, could improve the health outcomes and well-being of PWH in South Africa.ResumenLa mayoría de las medidas desarrolladas en países de ingresos altos para detectar el trastorno depresivo mayor (TDM) entre las personas que viven con el VIH (PVV) demuestran propiedades psicométricas subóptimas cuando se utilizan en entornos no occidentales de recursos limitados debido a sus altas tasas de falsos positivos. Para que la detección de TDM estandarizada sea implementable en entornos locales, se necesita una medida que reduzca la carga diagnóstica al ser altamente sensible mientras limita los falsos positivos. Este estudio trató de evaluar la capacidad de la Escala de Depresión Sudafricana (SADS, por sus siglas en inglés) desarrollada localmente para detectar TDM en PVV en Ciudad del Cabo. El SADS se administró junto con el SCID-5-RV como el test de referencia a 236 PWH. Demostró una buena capacidad discriminatoria en la detección de TDM con un área bajo la curva de 0,85. Un corte de 27 produjo un 78,2% de sensibilidad y un 54,4% de VPP. Dadas sus sólidas propiedades psicométricas, el uso rutinario del SADS en clínicas comunitarias para detectar las PVV en riesgo, combinado con un tratamiento de depresión basado en la evidencia, podría mejorar los resultados de salud y el bienestar de las PVV en Sudáfrica.