The impact of stigma on medication adherence among HIV-positive adolescent and young adult females and the moderating effects of coping and satisfaction with health care

Effectiveness of a mindfulness and acceptance-based intervention for improving the mental health of adolescents with HIV in Uganda: An open-label trial

Adolescents with HIV (AWH) face the double burden of dealing with challenges presented by their developmental phase while coping with stigma related to HIV, affecting their mental health. Poor mental health complicates adherence to daily treatment regimens, requiring innovative psychosocial support strategies for use with adolescents. We assessed the effectiveness of a mindfulness and acceptance-based intervention on the mental health of AWH in Uganda. One hundred and twenty-two AWH, mean age 17 ±1.59 (range 15 to 19 years), 57% female, receiving care at a public health facility in Kampala were enrolled in an open-label randomized trial (ClinicalTrials.gov: NCT05010317) with assessments at pre-and post-intervention. The mindfulness and acceptance-based intervention involved weekly 90-minute group sessions for four consecutive weeks facilitated by two experienced trainers. Sessions involved clarifying values, skillfully relating to thoughts, allowing and becoming aware of experiences non-judgmentally, and exploring life through trial and error. The control group received the current standard of care. Three mental health domains (depression, anxiety, and internalized stigma) were compared between the intervention and control groups. A linear mixed effects regression was used to analyze the effect of the intervention across the two time points. Results showed that the intervention was associated with a statistically significant reduction in symptoms of depression (β = -10.72, 95%CI: 6.25, -15.20; p < .0001), anxiety (β = -7.55, 95%CI: 2.66, -12.43; p = .0003) and stigma (β = -1.40, 95%CI: 0.66 to -2.15; p = .0004) over time. Results suggest that mindfulness and acceptance-based interventions have the potential to improve the mental health of AWH.

Stigma, coping strategies, distress and wellbeing in individuals with cervical dystonia: a cross-sectional study

Cervical dystonia (CD) is a movement disorder which causes sustained muscle contractions in the neck leading to abnormal postures and repetitive movements. As it is a highly visible condition, people with CD can experience stigma, which may lead to unhelpful coping strategies and increased psychological distress. This study investigated whether adaptive and maladaptive coping strategies mediate the relationship between stigma and psychological outcomes in people with CD. A total of 114 adults with CD completed measures of stigma, coping, health-related quality of life (HRQOL), psychological distress (depression, anxiety, stress), and psychological wellbeing at one time point. Participants' levels of distress were high, compared to the general population. Correlational analyses showed increased stigma and maladaptive coping (e.g. substance use, behavioural disengagement) were both significantly related to increased distress, lower wellbeing and lower HRQOL, whereas higher adaptive coping (e.g. acceptance, humour) was only related to higher wellbeing. In a parallel mediation model, maladaptive coping strategies mediated the relationship between stigma and distress, HRQOL and wellbeing, but adaptive coping strategies did not. These findings suggest that maladaptive coping may play an important role in explaining the relationship between stigma and some aspects of distress and wellbeing in CD. Interventions which focus on reducing different aspects of maladaptive coping may be helpful to improve wellbeing as well as reducing stigma.

Predictors of Viral Suppression Among People Living with HIV in Rural Oregon

With recent outbreaks of HIV in rural areas of the United States, it has become increasingly important to understand the factors affecting health outcomes of people with HIV living in rural areas. We assessed predictors of durable HIV viral suppression among rural participants using a pooled 7-year dataset from the Medical Monitoring Project (MMP), a cross-sectional, representative sample of individuals receiving HIV medical care in Oregon. Only 77.3% of rural participants achieved durable HIV viral suppression, while 22.7% had at least one detectable HIV viral load measurement within the past 12 months. The primary predictors of viral suppression were ARV adherence, poverty, and reported heavy drinking in the past 30 days. These results highlight the influence of social factors on health outcomes for persons with HIV living in rural areas and inform areas for policy and program change.

A qualitative analysis examining intersectional stigma among young adults living with HIV in Atlanta, Georgia

HIV-related stigma is a barrier to engagement in care for young adults living with HIV. Other intersecting forms of stigma (e.g., racism, sexism, homophobia), may worsen HIV-related stigma and impact engagement in care. From November 2020 to February 2021, we conducted 20 in-depth qualitative interviews among young adults living with HIV attending a large, comprehensive HIV care center in Atlanta, Georgia. Semi-structured interview guides based on Earnshaw and Chaudoir's HIV Stigma Framework and the theory of intersectionality facilitated discussion around experiences with various forms of stigma and its possible influence on healthcare engagement. Using the social-ecological model, we used thematic analysis to contextualize how young adults living with HIV experienced intersectional stigma and enacted, anticipated, and internalized HIV stigma in both healthcare and non-healthcare settings. Most participants identified as male, Black/African American, and gay. Participants described stigma at intrapersonal, interpersonal, clinic, and community levels. Intrapersonal stigma was associated with delayed care seeking, isolation, and fear of disclosure. Interpersonal stigma included discrimination from family and friends and avoidance of close relationships to elude disclosure. At the clinic level, stigma included negative experiences with staff in HIV and non-HIV healthcare settings, which contributed to decreased engagement in care. Stigma in the community included differential treatment from employers, community leaders, and religious community and was associated with feelings of helplessness related to current societal inequalities. Coping/motivating mechanisms for stigma included prioritizing health, eliciting support from the medical care team and peers. Our findings show different intersecting stigmas are barriers to healthcare at multiple levels for young adults living with HIV, potentially exacerbating existing health and social disparities. To improve engagement in care among young adults living with HIV, future interventions should address the different mechanisms of stigma at community, clinic, interpersonal and intrapersonal levels by enhancing social support and improving healthcare structural competency.

Intrapersonal predictors of internalized stigma among school going adolescents living with HIV in southwestern Uganda

We assessed the association between internalized HIV stigma, resilience, health locus of control, coping self-efficacy and empowerment among adolescents living with HIV in Uganda. We conducted a cross-sectional study between August and October 2020 among 173 adolescents aged 13-18 years attending Mbarara Regional Referral Hospital's HIV clinic. We used linear regression to determine the association between HIV stigma and intrapersonal factors adjusting for sociodemographic characteristics. The median age of the participants was 16 (IQR 3) years. There was a negative correlation between HIV stigma and resilience (β= -0.03, p < 0.001), internal health locus of control (β= -0.095, p < 0.001) and coping self-efficacy (β= -0.02, p < 0.001), while empowerment was positively correlated (β = 0.07, p < 0.001) with HIV stigma. After adjusting for the intrapersonal factors (resilience, health locus of control, coping self-efficacy and empowerment) and socio-demographic characteristics (education level and boarding school), only internal health locus of control (β=-0.044, p = 0.016) and coping self-efficacy (β=-0.015, p < 0.001) remained significantly correlated with HIV stigma. The findings suggest that interventions focusing on intrapersonal factors such as internal locus of control, empowerment and resilience may contribute towards reduction of HIV stigma among adolescents in boarding schools.

Associations of psychological inflexibility with posttraumatic stress disorder and adherence to COVID-19 control measures among refugees in Uganda: The moderating role of coping strategies

Refugees are vulnerable to developing mental health problems. The unprecedented appearance and rapid spread of COVID-19 exacerbated this vulnerability, especially in low-income countries where refugees survive on humanitarian aid and live in congested settlements. These appalling living conditions are a stressor, making adherence to COVID-19 control measures impractical and an additional psychological strain for refugees. The present study examined how psychological inflexibility is associated with adherence to COVID-19 control measures. A sample of 352 refugees from Kampala City and Bidibidi settlements were recruited. Refugees with high levels of psychological inflexibility reported higher PTSD symptom severity and low adherence to COVID-19 control measures. Moreover, PTSD severity mediated the association between psychological inflexibility and adherence, while avoidance coping moderated both direct and indirect effects. Interventions for reducing psychological inflexibility and avoidance coping may be essential in boosting adherence to measures relevant to the current and future status of the pandemic, along with other crises that refugees face.

Virological failure and adherence to antiretroviral therapy in adolescents and young adults living with human immunodeficiency virus

OBJECTIVE

HIV (human immunodeficiency virus) infection remains a major public health challenge. Infected young people at any age are less likely to adhere to care in a timely manner and to maintain a suppressed VL. This review aims to identify factors associated with virologic failure and adherence to drug therapy in adolescents and young adults (10-24 years) living with HIV.

METHODS

Systematic review using the PubMed and Virtual Health Library databases and including articles published between 2009 and 2021. Data were analysed in six categories: individual factors, pharmacological/therapy-related aspects, factors related to HIV/acquired immunodeficiency syndrome (AIDS) infection, HIV/AIDS stigma, social support and health system/services. The study's protocol was registered on the PROSPERO platform (CRD42020167581).

RESULTS

A total of 19,819 articles were found in the initial search and 31 studies were included in this systematic review. Most studies were carried out on the African continent. Male sex, alcohol use, low education, adverse effects of medication, lack of social support, stigma related to HIV/AIDS, need for transportation to access the health service and forgetfulness were linked to poor adherence to therapy. Good adherence was achieved with sufficient nutrition, good social support, greater confidence in the use of therapy and fewer ART side effects. Low levels of CD4, alcohol use, substance abuse, low education, non-adherence to medication and forgetfulness were linked to virological failure.

CONCLUSION

Individual, social and structural factors constitute barriers to adherence to ART among adolescent and young adults. It is necessary to know the difficulties related to the use of therapy to work out specific strategies that create conditions to improve medication adherence and viral suppression, reducing the levels of virological failure in this population.

Person-centred language and HIV research: a cross-sectional examination of stigmatising terminology in medical literature

OBJECTIVE

We sought to quantify the use of person-centred language (PCL) in research journals that publish high volumes of HIV-related manuscripts.

DESIGN

In this cross-sectional study, we searched PubMed for HIV-related articles published between 1 January 2017 and 7 March 2021. After journal reduction and article randomisation, title and abstract screening was conducted among 500 studies in a masked, duplicate fashion.

METHODS

Studies that were included were systematically searched for prespecified, stigmatising terms, partial terms and phrases. Prevalence rates of non-person-centred terminology were totalled, and the total number of articles adherent to PCL guidelines were reported. Fisher's exact tests were used to determine associations between PCL adherence and article funding source, type of article, continent of origin and research, among others.

RESULTS

Among 237 studies included, 21.52% (51) of HIV-related publications in this cross-sectional analysis were found to be PCL adherent. Stigmatising labels such as 'HIV- or AIDS-infected' and 'HIV- or AIDS-person or patient' were used most frequently, with the former appearing in 57.38% of articles and the latter appearing in 30.80% of articles.

CONCLUSION

Despite numerous guidelines and requirements for the use of PCL in research, our findings suggest that an alarming number of HIV-related articles are not following these guidelines. This is concerning because this labelling likely contributes to the persistence of stigma in HIV-centred care. The intentional use of person-centred language in medical research has the potential to minimise the use of stigmatising language among medical professionals, in medical education, in medical records and patient encounters, and thus reduce stigma.

HIV care cascade for women living with HIV in the Greater Toronto Area versus the rest of Ontario and Canada

BACKGROUND

The Greater Toronto Area (GTA) is home to 39% of Canada's population living with HIV. To identify gaps in access and engagement in care and treatment, we assessed the care cascade of women living with HIV (WLWH) in the GTA versus the rest of Ontario and Canada (in this case: Quebec and British Columbia).

METHODS

We analyzed 2013-2015 self-reported baseline data from the Canadian HIV Women's Sexual and Reproductive Health Cohort Study for six care cascade stages: linked to care, retained in care, initiated antiretroviral therapy (ART), currently on ART, ART adherence (≥90%), and undetectable (<50 copies/mL). Multivariable logistic regression was used to reveal associations with being undetectable.

RESULTS

Comparing the GTA to the rest of Ontario and Canada, respectively: 96%, 98%, 100% were linked to care; 92%, 94%, 98% retained in care; 72%, 89%, 96% initiated ART; 67%, 81%, 90% were currently using ART; 53%, 66%, 77% were adherent; 59%, 69%, 81% were undetectable. Factors associated with viral suppression in the multivariable model included: living outside of the GTA (Ontario: aOR = 1.72, 95% CI: 1.09-2.72; Canada: aOR = 2.42, 95% CI: 1.62-3.62), non-Canadian citizenship (landed immigrant/permanent resident: aOR = 3.23, 95% CI: 1.66-6.26; refugee/protected person/other status: aOR = 4.77, 95% CI: 1.96-11.64), completed high school (aOR = 1.77, 95% CI: 1.15-2.73), stable housing (aOR = 2.13, 95% CI: 1.33-3.39), income of ≥$20,000 (aOR = 1.52, 95% CI: 1.00-2.31), HIV diagnosis <6 years (6-14 years: aOR = 1.75, 95% CI: 1.16-2.63; >14 years: aOR = 1.87, 95% CI: 1.19-2.96), and higher resilience (aOR = 1.02, 95% CI: 1.00-1.04).

CONCLUSION

WLWH living in the GTA had lower rates of viral suppression compared to the rest of Ontario and Canada even after adjustment of age, ethnicity, and HIV diagnosis duration. High-impact programming for WLWH in the GTA to improve HIV outcomes are greatly needed.

A model for explaining adherence to antiretroviral therapy in patients with HIV/AIDS: A grounded theory study

Maintaining a high level of adherence to antiretroviral therapy is a challenge among HIV/AIDS patients. The study aimed to explore the process of adherence to treatment with a grounded theory approach to help physicians and planners develop strategies to increase adherence to treatment. We conducted in-depth interviews and a focus-group discussion. The data were collected from 2016 to 2018. The participants were 39 HIV/AIDS patients treated with antiretroviral, their relatives (three people) and two treatment staff. The study was conducted at the Behavioural Counselling Center of Imam Khomeini Hospital, located in Tehran, the capital of Iran. The data were analysed at the stages of "analysis for concepts," "analysis for context," "bringing process into the analysis" and "integrating." We obtained a conceptual model to explain the relationship between the categories. "Motivation" was identified as the core variable and the "Becoming resilient" explained the adherence process. Several factors including the interfering factors, contextual factors and resilience factors were identified. The interfering and contextual factors, in the absence of the resilience factors, lead to decreased motivation and increased poor adherence to treatment. The role of motivation in long-term adherence should be emphasised. We think strategies such as helping individuals with HIV/AIDS to form support networks, empowering and encouraging them to seek spiritual help will motivate them to maintain a long-term use of antiretroviral medications and, hence, become more resilient.

A Multilevel Integrated Intervention to Reduce the Impact of HIV Stigma on HIV Treatment Outcomes Among Adolescents Living With HIV in Uganda: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda.

OBJECTIVE

The proposed intervention-Multilevel Suubi (MSuubi)-has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants' experiences with HIV stigma, HIV treatment adherence, and intervention and educators' attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training.

METHODS

MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months.

RESULTS

This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025.

CONCLUSIONS

MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40101.

Digital directly observed therapy to monitor adherence to medications: a scoping review

Background: Technology-based directly observed therapy (DOT) is more cost-effective and efficient compared with in-person monitoring visits for medication adherence. While some evidence shows these technologies are feasible and acceptable, there is limited evidence collating information across medical conditions or in the context of HIV prevention, care, and treatment.Objectives: We conducted a scoping review to understand the current evidence on the acceptability, feasibility, and efficacy of digital DOT to improve medication adherence and, specifically, to determine if digital DOT had been used to improve adherence for HIV prevention, care, and treatmentMethods: We searched the electronic databases PubMed, Embase, and the Web of Science in January 2021 for any published studies with terms related to digital technologies and DOT. We included peer-reviewed studies in any population, from any country, for any outcome, and excluded conference abstracts. We included three types of digital DOT interventions: synchronous DOT, asynchronous DOT, and automated DOT. We provide an assessment of the current evidence, gaps in literature, and opportunities for intervention development regarding the use digital DOT to improve antiretroviral therapy (ART) adherence, specifically in the field of HIV.Results: We identified 28 studies that examined digital DOT. All studies found digital DOT to be acceptable and feasible. Patients using digital DOT had higher rates of treatment completion, observed doses, and adherence compared with in-person DOT, although data were limited on adherence. Only one study examined HIV prevention, and none examined ART adherence for HIV treatment.Conclusions: Digital DOT is acceptable and feasible but has not been used to remotely monitor and support ART adherence for people living with HIV.

Effects of psychosocial factors on nonadherence to ART in Ganta, Nimba county, Liberia

Background

It has been widely noted that lifetime adherence to antiretroviral therapy (ART) is necessary for HIV treatment outcome; however, retention on ART among people living with HIV (PLWH) remains a great challenge to achieve the Global AIDS Strategy: End inequalities, End AIDS. Nonadherence to ART is one of the HIV care problem in Liberia despite the availability of free ART. Psychosocial factors, i.e., perceived stigma and social support likely contributed to nonadherence to ART. We investigated associations among clinical factors, psychosocial factors, and nonadherence to ART.

Methods

A community-based cross-sectional study was conducted among 185 PLWH, age ≥ 18 years receiving ART in Ganta, Nimba county, Liberia at least 3 months. The structured questionnaire was used to collect data from April to May 2020. Associated factors of nonadherence to ART were identified using multivariable binary logistic regression, and the p-value < 0.05 was considered statistically significant.

Results

Of 185 respondents, 62.2% showed nonadherence to ART. Females reported higher nonadherence compared with males (64.4% vs. 56.6%). Multivariable binary logistic regression revealed strong experiences of stigma (PORadj = 2.392, p-value = 0.018), poor information support (PORadj = 2.102, p-value = 0.026) increased prevalence of ART nonadherence among Liberian PLWH.

Conclusions

The healthcare providers may apply interventions to reduce perceived stigma and to enhance continuous information provision in addition to support from health care providers and family members. An intensive monitoring of ART side effects is needed to be strengthened in particular among newly started ART patients.

Using Participatory Methods to Assess PrEP Interest and Uptake Among Young People Living in the Southeastern US: A Mixed Methods Assessment

Adolescents and young adults (AYA; 13-24 years-old) comprise 22% of new HIV infections in the United States (US), most of whom live in the South. We used the situated-Information, Motivation, Behavioral skills (sIMB) model to identify priorities for intervention on multi-level factors that influence HIV preventive care among Black AYA in Durham, North Carolina. We conducted two participatory workshops (ages 13-17, N = 6; ages 18-24, N = 7) to engage youth about how to discuss HIV. We also assessed sIMB constructs from a separate quantitative sample of youth to contextualize the workshop findings (N = 80). HIV knowledge was low overall, but lower among younger Black AYA, suggesting a need for comprehensive sexual education. Trusted adults provided sexual health information, motivation for health maintenance, and behavioral skills support. HIV prevention interventions should provide comprehensive sexual health education to Black AYA, be age-specific, and include social supporters like parents, teachers, and community members.

Assessing Different Types of HIV Communication and Sociocultural Factors on Perceived HIV Stigma and Testing among a National Sample of Youth and Young Adults

In the United States, racial/ethnic and sexual youth and young adults (YYA) of color are disproportionately affected by HIV. Subsequently, YYA experience HIV stigma and engage in increased risk behaviors and reduced HIV testing. HIV communication has been identified as a potential buffer to HIV stigma, resulting in health-seeking behaviors, such as HIV testing. In this study, we respond to a meaningful gap in the literature by examining different types of HIV communication and their impact on HIV stigma and HIV testing in a diverse sample of YYA. We analyzed secondary data from the Kaiser Family Foundation National Survey of Teens and Young Adults on HIV/AIDS. A 40-question, web-based survey was conducted with 1437 youth (ages 15-24). Recruitment included a dual sampling method from households with: (1) listed phone numbers, (2) unlisted phone numbers, (3) telephones, (4) no telephone, and (5) only cell phone access. The purpose of the survey was to establish participants' HIV knowledge, communication, experiences, and testing behaviors. Findings suggested an association between intimate-partner HIV communication, increased HIV testing, and reduced HIV stigma. We also identified differentials in HIV testing and stigma based on gender, income, age, and sexual minority status, explained by HIV communication. Further research is needed that examines ways to use intimate-partner HIV communication to reduce stigma and increase HIV testing among YYA of different sociodemographic characteristics and sexual orientations.

Psychometric Properties of the Berger HIV Stigma Scale: A Systematic Review

Addressing HIV-related stigma requires the use of psychometrically sound measures. However, despite the Berger HIV stigma scale (HSS) being among the most widely used measures for assessing HIV-related stigma, no study has systematically summarised its psychometric properties. This review investigated the psychometric properties of the HSS. A systematic review of articles published between 2001 and August 2021 was undertaken (CRD42020220305) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additionally, we searched the grey literature and screened the reference lists of the included studies. Of the total 1241 studies that were screened, 166 were included in the review, of which 24 were development and/or validation studies. The rest were observational or experimental studies. All the studies except two reported some aspect of the scale's reliability. The reported internal consistency ranged from acceptable to excellent (Cronbach's alpha ≥ 0.70) in 93.2% of the studies. Only eight studies reported test-retest reliability, and the reported reliability was adequate, except for one study. Only 36 studies assessed and established the HSS's validity. The HSS appears to be a reliable and valid measure of HIV-related stigma. However, the validity evidence came from only 36 studies, most of which were conducted in North America and Europe. Consequently, more validation work is necessary for more precise insights.

High Perceived Stigma Among People Living with HIV/AIDS in a Resource Limited Setting in Western Ethiopia: The Effect of Depression and Low Social Support

Background

Antiretroviral therapy (ART) is only one part of a successful range of care among people living with HIV/AIDS (PLWHA). Stigma and low social support are emerging issues worsening the success of ART for PLWHA. This study thus aimed to investigate the level of perceived stigma among PLWHA.

Methods

An institution-based cross-sectional study was conducted in Nekemte, western Ethiopia. A multivariable logistic regression model was used to identify associations between perceived stigma and low social support, depression, and other potential predictor variables using SPSS version 24.0 and adjusted odds ratios (AORs), considering statistical significance at p<0.05.

Results

A total of 418 study participants were included in the study, with a response rate of 100%. About 48.6% of PLWHA had experienced perceived stigma, and more than two-fifths had poor social support. The following factors were associated with perceived stigma among PLWHA: age (18-29 years) (AOR=4.88, 95% CI:1.76-13.5), female sex (AOR=2.10, 95% CI 1.15-3.82), <12 months on ART (AOR=2.63, 95% CI 1.09-6.34), depression (AOR=1.86, 95% CI 1.08-3.19), social support (poor: AOR=3.45, 95% CI 1.65-7.23; medium: AOR=2.22, 95% CI 1.09-4.54), and non-disclosure of HIV status (AOR=2.00, 95% CI 1.11-3.59).

Conclusion and Recommendation

The magnitude of perceived stigma among PLWHA was high, highlighting the importance of integrating social and mental health support within standard ART for PLWHA.

Socioeconomic, clinical, and behavioral characteristics of adolescents living with HIV in Southwest Nigeria: implication for preparedness for transition to adult care

There is a need to generate data that demonstrate preparedness (or a lack of it) of adolescents to crossover to adult care to inform policy and create appropriate models in LMICs. This cross-sectional survey of 252 adolescents (15-19 years) receiving HIV-care assessed sociodemographic characteristics, clinical and ART status, and HIV-related behaviors. Also, the study appraised HIV status awareness, and disclosure, and access to healthcare. The mean age of the participants was 16.41 (SD = 1.41) years, and 128 (50.8%) of them were female. The mean adherence level (by VAS) reported was 73.05 ± 16.75. The most frequently reported reasons for missing medications were forgetting (39.6%), falling asleep (37.7%), being away from home (33.8%), and being too busy with other endeavors (32.6%). Most (93.7%) of the participants paid for health care services out-of-pocket. Many (38.1%) of them did not know how they acquired HIV infection. About half (44.8%) of them had boy/girlfriends, but only 25 (9.9%) reported ever having sex. Only 4% disclosed their HIV status to their boy/girlfriends. Critical gaps exist in adolescents' preparedness for transition to adult HIV-care, necessitating the need for specific transition preparedness programs within the HIV-care cascade to address the peculiar needs of adolescents at this stage.Trial registration: ClinicalTrials.gov identifier: NCT03394391.

Stigma reduction: an essential ingredient to ending AIDS by 2030

Ending the AIDS epidemic by 2030 will require addressing stigma more systematically and at a larger scale than current efforts. Existing global evidence shows that stigma is a barrier to achieving each of the 90-90-90 targets; it undermines HIV testing, linkage to care, treatment adherence, and viral load suppression. However, findings from both research studies and programmatic experience have helped to inform the growing body of knowledge regarding how to reduce stigma, leading to key principles for HIV stigma reduction. These principles include immediately addressing actionable drivers of stigma, centring groups affected by stigma at the core of the response, and engaging opinion leaders and building partnerships between affected groups and opinion leaders. Although there is still room to strengthen research on stigma measurement and reduction, in particular for intersectional stigma, the proliferation of evidence over the past several decades on how to measure and address stigma provides a solid foundation for immediate and comprehensive action.

Proportion of Depression and Its Associated Factors Among Youth HIV/AIDS Clients Attending ART Clinic in Dessie Town Government Health Facilities, Northeast Ethiopia

BACKGROUND

Depression is the most prevalent among people living with HIV/AIDS than people without HIV/AIDS. Depression is associated with an increase in morbidity and mortality in people living with HIV/AIDS and adversely affects the adherence to antiretroviral therapy, quality of life, and health-related parameters.

OBJECTIVE

The aim of this study was to assess the proportion of depression and its associated factors among youth HIV/AIDS patients attending ART clinics in Dessie town Government health facilities, Northeast Ethiopia.

METHODS

Institutional-based cross-sectional study design was employed on 431 youth HIV/AIDS patients attending ART clinics at Dessie town Public health facilities. Data were collected by face-to-face interview using a structured questionnaire. EPI-Data software version 3.1 was used to enter the data and analysis was done using SPSS version 23. Binary logistic regression was used to identify factors associated with depression. Statistical significance was declared at a p-value of less than 0.05 in the final model.

RESULTS

The proportion of depression among youth HIV/AIDS patients was 26.2%. The age range between 20 and 24 years (AOR = 2.019, 95% CI: 1.143-3.566), poor medication adherence (AOR = 9.007, 95% CI: 3.061-26.500), stigma (AOR = 4.14, 95% CI: 2.08-8.26), and low social support (AOR = 1.854, 95% CI: 1.034-3.324) were associated with depression.

CONCLUSION

The proportion of depression among youth HIV patients in the current study was found to be lower compared to previous studies. Age, HIV-related stigma, social support, lost job, and poor medication adherence were found to be independent predictors of depression. Therefore, scaling up the pediatric psychosocial support program to youth psychosocial support for all ART site health facilities, strengthening health education about the medication adherence and complication of HIV/AIDS are needed.

The ongoing HIV epidemic in American youth: challenges and opportunities

The incidence of human immunodeficiency virus (HIV) infection has been decreasing in the United States overall, except among youth, and in particular among Black and Latinx young men who have sex with men (MSM). In this review we summarize key drivers of the HIV epidemic among youth, as well as novel interventions geared specifically towards combating the epidemic among high-risk populations. Many factors driving the HIV epidemic among youth are related to systemic inequities, including lack of access to healthcare, inadequate education, and internalized and experience homophobia and racism. Developmentally, youth may feel that they are invulnerable and be willing to engage in risks. Moreover, HIV is often invisible for youth given advances in treatment and community stigma, limiting open discussion of risk and new preventive modalities. Outcomes from the HIV treatment cascade suggest that youth are less likely to be aware of their HIV infection status, less likely to link to and be engaged in care, and less likely to be virologically suppressed than older MSM and other populations of people living with HIV. Importantly, pre-exposure prophylaxis (PrEP) has been shown to be an effective tool for prevention of HIV infection that also appears to have disproportionately poor uptake among youth. Barriers to PrEP utilization appear to be quite heterogeneous, and include patient-, provider-, and structural-level barriers. Interventions important in improving HIV prevention will thus have to be multipronged and developed for culturally diverse populations. Cognitive behavioral therapy-based interventions are promising strategies as they are able to address a diverse array of barriers. New formulations of PrEP will also likely be instrumental in improving adherence. Since youth spend considerable amounts of time accessing digital media, the deployment of apps and other mobile phone-based interfaces offer unique opportunities to increase education and to facilitate HIV prevention for at risk youth. Multiple studies are underway to better inform the optimal delivery of treatment and prevention services for this complex and diverse population, and include novel sociobiological interventions and new modes of medication delivery that may lend themselves to overcoming obstacles specific to youth.

Prevalence and Factors Associated With Suicidal Ideation Among Children and Adolescents Attending a Pediatric HIV Clinic in Uganda

Background: Suicidal behavior and HIV/AIDS are vital public health challenges especially in low and middle-income countries. As suicide in adults is perturbing for those closest to them, this sentiment is much more intense and generalized in the case of a child or adolescent. Knowledge of factors associated with suicidal ideation in HIV infected children and adolescents may inform suicide prevention strategies needed to improve their quality of life. This study aimed to assess the prevalence and factors associated with suicidal ideation among HIV infected children and adolescents attending a pediatric HIV clinic in Uganda. Methods: Data from a sample of 271 children and adolescents aged 6-18 years living with HIV/AIDS attending a pediatric HIV clinic was analyzed. Child characteristics and clinical variables were assessed using a socio-demographic questionnaire and medical records respectively. Suicidal ideation and depression were assessed using the Child Depression Inventory. The types of behavioral problems and the parent-child relationship were assessed using Child Behavioral Check List (6-18 years) and the Parent Child Relationship Scale respectively. Child exposure to different stressful life events was assessed with a series of standardized questions. Logistic regression models were used to explore factors independently associated with suicidal ideation. Results: The prevalence of suicidal ideation was 17%. In the multivariate analysis; Child exposure to family or friend's death (prevalence rate ratio (PRR = 2.02; 95% CI, 1.01-4.03), p = 0.046), HIV wasting syndrome (PRR = 0.39; 95% CI, 0.21-0.75, p = 0.04), Depression (PRR = 1.08; 95% CI, 1.03-1.12, p = 0.001), Anxiety symptoms (PRR = 1.10; 95% CI, 1.01-1.20, p = 0.024) and Rule breaking behavior (PRR = 1.06; 95% CI, 0.99-1.13, p = 0.051) were independently associated with suicidal ideations. Conclusion: The prevalence of suicidal ideation among children and adolescents living with HIV/AIDS is substantial. Children and adolescents with exposure to family or friend's death, those with higher depression scores, anxiety symptoms and rule breaking behavior are more likely to report suicidal ideation. Those with HIV wasting syndrome were less likely to report suicidal ideation. There is urgent need for HIV care providers to screen for suicide and link to mental health services.

Challenges to Antiretroviral Therapy Adherence and Coping Strategies to Overcome Them: Qualitative Investigations of Adolescents Living with HIV, their Caregivers, and Clinicians in Vietnam

Background:

Adolescents living with HIV (ALHIV) in Vietnam are known to struggle with adherence to Antiretroviral Therapy (ART).

Objective:

To examine treatment challenges and facilitators experienced by ALHIV from the perspective of adolescents, their caregivers, and providers, and to inform an adherence intervention.

Methods:

In-depth Interviews (IDIs) of adolescent/caregiver dyads and Focus Group Discussions (FGDs) with adolescents, caregivers, and clinicians were conducted in Hanoi, Vietnam. We used semi-structured guides to encourage open-ended responses. We queried the challenges adolescents experience taking ART medications and being adherent, their awareness of disease status, and facilitators to support high adherence. Audio-recorded IDIs were translated into English, and coded and analyzed in NVivo using a thematic approach.

Results:

A total of 78 individuals participated in the study. Forty individuals participated in IDIs (20 adolescents and 20 caregivers). All adolescents had acquired HIV perinatally. We conducted six FGDs: four with adolescents, and one each with caregivers and clinicians. We identified major themes regarding awareness of HIV status (most caregivers reported they had disclosed to their child, while few adolescents revealed the knowledge of their status); perceived barriers to adherence (medication-related challenges, stigma, school-associated issues, financial obstacles, system challenges, awareness of HIV status); and adherence facilitators (development of dose-taking habits, reminder systems, social support). Differences between adolescents and caregivers related to key issues were evident.

Conclusion:

Further research is needed to elucidate discrepancies in adolescent-caregiver viewpoints and develop interventions tailored to both ALHIV and their caregivers.

A total facility approach to reducing HIV stigma in health facilities: implementation process and lessons learned

OBJECTIVES

To describe development and implementation of a three-stage 'total facility' approach to reducing health facility HIV stigma in Ghana and Tanzania, to facilitate replication.

DESIGN

HIV stigma in healthcare settings hinders the HIV response and can occur during any interaction between client and staff, between staff, and within institutional processes and structures. Therefore, the design focuses on multiple socioecological levels within a health facility and targets all levels of staff (clinical and nonclinical).

METHODS

The approach is grounded in social cognitive theory principles and interpersonal or intergroup contact theory that works to combat stigma by creating space for interpersonal interactions, fostering empathy, and building efficacy for stigma reduction through awareness, skills, and knowledge building as well as through joint action planning for changes needed in the facility environment. The approach targets actionable drivers of stigma among health facility staff: fear of HIV transmission, awareness of stigma, attitudes, and health facility environment.

RESULTS

The results are the three-stage process of formative research, capacity building, and integration into facility structures and processes. Key implementation lessons learned included the importance of formative data to catalyze action and shape intervention activities, using participatory training methodologies, involving facility management throughout, having staff, and clients living with HIV facilitate trainings, involving a substantial proportion of staff, mixing staff cadres and departments in training groups, and integrating stigma-reduction into existing structures and processes.

CONCLUSION

Addressing stigma in health facilities is critical and this approach offers a feasible, well accepted method of doing so.

Unmet needs of symptom management and associated factors among the HIV-positive population in Shanghai, China: A cross-sectional study

BACKGROUND

People living with HIV/AIDS (PLWHA) are a vulnerable group who experience multiple physiological and psychological symptoms. A better understanding of unmet symptom management needs will allow researchers to design interventions that are more reflective of deficits in care and more effective at improving patient care. Few studies have focused on unmet needs for symptom management in PLWHA particularly in China. Factors influencing Chinese PLWHA symptom management needs are rarely discussed.

AIM

The purpose of this study was to investigate the unmet needs for symptom management of PLWHA and how their symptom burden, HIV perceived stigma, and self-management capacity contributes to HIV-related self-management practices in Shanghai, China.

DESIGN

Study participants were recruited from the outpatient and inpatient HIV/AIDS wards in an infectious hospital in Shanghai, China. Self-administered questionnaires were implemented and medical charts were reviewed.

RESULTS

A total of 367 participants was recruited from April to September 2017. The results show that 53.1% (195 of 367) of participants presented at least one unmet symptom management need and that symptom burden, as well as perceived stigma, reduced self-management capacity, and no employment significantly affected unmet symptom management needs.

CONCLUSION

The findings indicate that there is room for improvement in symptom management for Chinese PLWHA. Culturally appropriate interventions focusing on improving symptom burden, decreasing HIV perceived stigma, and enhancing self-management capacity can enhance symptom management in this population.

Experiences and effects of HIV-related stigma among youth living with HIV/AIDS in Western Uganda: A photovoice study

HIV-related stigma has been identified as a significant stressor affecting Quality of Life of Youth Living With HIV/AIDS (YLWHA). Gaining a contextualized understanding of how this stigma is experienced by YLWHA in Western Uganda is crucial in addressing it in this group and setting. In this study, we explored the lived experiences of YLWHA with HIV-related stigma. Photovoice was used to gain insight into the lived experiences of HIV-related stigma in 11 YLWHA (15–19 years), purposively selected from a hospital-based peer support group. Group interview transcripts, notes and photographs were subjected to phenomenological hermeneutic analysis. Encounters with enacted, anticipated and internalized stigmas and their myriad sequels were prevalent in the photos and narratives of participants. Our findings were categorized and presented in 5 main themes that were identified through the analysis: being devalued, experiencing fear, experiencing injustices, feeling lonely, and lacking future perspectives. HIV-related stigmas were experienced in various socio-ecological domains but predominantly in homes and schools that ought to be supportive surroundings for youths. A multilevel approach, targeting the entire society where the root causes of stigma can be found and specific contexts like schools and homes where youth are confronted with stigma on a daily basis is proposed for a wholistic intervention.

Urban-rural disparity in sociodemographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women and their perspectives on their male sexual partners: A cross-sectional study in Zimbabwe

We conducted a cross sectional survey in Zimbabwe to describe urban-rural disparity in socio-demographic characteristics and sexual behaviors of HIV-positive adolescent girls and young women (AGYW) and their male sexual partners. Between September and November 2016, we interviewed 360 sexually active HIV positive AGYW, aged 15––24 years attending ART and PMTCT clinics in urban and rural health facilities in Harare and Mazowe district respectively. HIV positive AGYW in rural areas as compared to those in urban areas were older, less educated, more frequently married or cohabiting, had lower number of male sexual partners in their lifetime and in the last 12 months preceding the survey. They were mostly heterosexually infected, more likely to disclose their status to a family member and to be more adherent to ART (OR = 2.5–95% CI = 1.1–5.5). Most recent male sexual partners of HIV positive AGYW in urban areas as compared to those from rural areas were mainly current or former boyfriends, single, more educated, less likely to have a child with them and to engage in couple voluntary counseling and testing (CVCT). They were more likely to patronize dancing and drinking venues and involved in transactional sex (OR = 2.2–95% CI: 1.2–4). They were also more likely to be circumcised (OR = 2.3–95% CI: 1.3–4.1) and to use condom more consistently in the last 12 months preceding the survey. Our study findings called for the strengthening of HIV prevention interventions in urban areas among HIV positive AGYW who had more than one partner in their lifetime or are patronizing dancing and drinking venues. In Zimbabwe, promotion of CVCT, index testing, male circumcision and condom use should be sustained to engage male sexual partners of both urban and rural HIV positive AGYW in HIV prevention.

Developing Prepare2Thrive, a community-based intervention targeting treatment engagement among African American individuals living with HIV and serious mental illness

African American individuals living with HIV and serious mental illness (SMI) may report relatively low treatment engagement, despite treatment engagement being critical to managing both health conditions. Here, we have two aims: to describe the methodology we used to collect focus group data on treatment engagement with a sample of African American individuals living with HIV and SMI, and to describe the results of those focus groups in the context of intervention development. We conducted two focus groups (N = 15), integrating a social-ecological model for our theoretical framework, Community-Based Participatory Research for study design and execution, and group concept mapping for data analysis. Three thematic clusters relating to treatment engagement emerged from each group, with overlap across groups: Medication knowledge, Patient-provider relationships, and Barriers to treatment engagement. Items related to the Patient-provider relationship loaded onto all emergent clusters, demonstrating the pervasive impact of this variable. Findings informed the design of Prepare2Thrive, a community-based, culture-specific intervention aiming to increase treatment engagement among African American individuals living with HIV and SMI. Both our design and findings can be used in future collaborations aiming to maximize treatment engagement, and more broadly health, among individuals in this community.

The Transition of Care From Pediatric to Adult Health-Care Services of Vertically HIV-Infected Adolescents: A Pilot Study

Objective: Clinical and psychological HIV-related problems peak during adolescence, which coincides with transition of children and adolescents infected from mothers from pediatric to adult reference centers for HIV infection. Transition often is done without specific programs. We wanted to explore transition as an opportunity to increase the efficacy of care and the psychological well-being through a specific program. Methods: Thirteen vertically infected patients aged 13-20 years were followed up for 24 months by pediatricians, infectious disease specialists, a psychologist, and a nurse. Interventions consisted in joint clinic, simplification of therapy, patient group discussions, HIV infection explanations, and psychological support, lasting 12 months. Efficacy was measured by viro-immunological outcomes and adherence to therapy and psychological tests. Clinical, viro-immunological, and psychological evaluations were performed at 0 (T0) and 12 months (T12) and 6 months after transition to an adult center (T18). Psychological outcomes were assessed using standardized questionnaires for quality of life and self-esteem. Results: In 11/13 participants, pills administrations/day were significantly reduced. Patients with undetectable viral load and CD4+ >25% increased from 61 to 77% and from 61 to 74%, respectively. Six months after transition, all patients exhibited an undetectable viral load. Adolescents' awareness of the severity of the disease and the risk of sexual transmission was generally poor. Patients classified with "severe" psychological distress according to the quality of life index decreased from 38 to 15% and well-being increased. Similar results were observed 6 months after the transition to adult care. No effect was observed on self-esteem index. Conclusions: Specific protocols for transition should be developed to optimize resilience and psychological well-being, including routine psychological support for adolescents with HIV infection transiting from pediatric to adult centers for HIV infection.

The magnitude of suicidal ideation, attempts and associated factors of HIV positive youth attending ART follow ups at St. Paul's hospital Millennium Medical College and St. Peter's specialized hospital, Addis Ababa, Ethiopia, 2018

Background

Suicide which is considered a psychiatric emergency, is a serious cause of mortality worldwide. Youth living with HIV/AIDS (YLWHA) have higher rates of suicidal behavior than the general public. This study aimed to assess the magnitude and associated factors of suicide ideation and attempt among the Human Immune deficiency Virus (HIV) positive youth attending anti-retroviral therapy (ART) follow up at St. Paul`s hospital Millennium Medical College and St. Peter`s specialized hospital, Addis Ababa, Ethiopia.

Methods

In this cross-sectional study, 413 HIV positive youth were recruited for interviews, using the systematic random sampling technique. The Composite International Diagnostic Interview (CIDI) was used to assess suicide. PHQ-9, the Oslo social support and HIV perceived stigma scale instruments were used to assess the factors. We computed bivariate and multivariable binary logistic regressions to assess factors associated with suicidal ideation and attempt. Statistical significance was declared at P-value <0.05.

Result

The magnitude of suicidal ideation and attempts were found to be 27.1% and 16.9%, respectively. In the multivariate analysis, female sex (adjusted odd ratio(AOR) = 3.1, 95% CI, 1.6–6.0), family death (AOR = 2.1, 95%CI 1.15–3.85), WHO clinical stage III of HIV (AOR = 3.1 95% CI 1.3–7.35), WHO clinical stage IV of HIV (AOR = 4.76, 95%CI, 1.3–7.35), co-morbid depression (AOR = 7.14, 95%CI, 3.9–12.9), and perceived HIV stigma (AOR = 4.2, 95%CI, 2.27–8.2) were significantly associated with suicidal ideation, whereas female sex (AOR = 4.12, 95%CI, 1.82–9.78), opportunistic infections (AOR = 3.1, 95%CI, 1.6–6.04), WHO clinical stage III of HIV (AOR = 3.1 95%CI 1.24–7.81), co-morbid depression (AOR = 5.6 95% CI, 2.8–11.1), and poor social support (AOR = 3.4, 95%CI, 1.2–9.4) were statistically significant with suicidal attempt. The result suggests that the magnitude of suicidal ideation and attempts among HIV positive youth were high. We recommend that clinicians consider youth with comorbid depression, perceived HIV stigma and poor social support.

Stigma and suicidality among people living with HIV attending a secondary healthcare facility in Nigeria

PURPOSE

To ascertain the relationship between HIV-related stigma and suicidality among people living with HIV receiving care at a hospital in Nigeria.

DESIGN AND METHODS

Four hundred and ten participants were administered a socio-demographic and clinical history questionnaire, the 40-item Berger's HIV-stigma scale, and the Mini International Neuropsychiatric Interview (MINI) to diagnose suicidality and depression in a cross-sectional study.

FINDINGS

Fifty-four (13.2%) reported suicidality; suicidal ideation was commonest and suicide plans least, in the month preceding the study. Higher suicidality risk was significantly associated with stigma (P < 0.001) and major depressive disorder ( P < 0.001).

PRACTICE IMPLICATIONS

Suicidality is common and is associated with HIV-related stigma.

Religion and HIV-Related Stigma among Nurses Who Work with People Living with HIV/AIDS in Puerto Rico

HIV-related stigma among nurses can impact health care services for people with HIV/AIDS (PWHA). health care professionals' religious views can potentially foster stigmatizing attitudes. There is scarce scientific literature exploring the role of religion on HIV/AIDS stigma among nurses. This study aimed to explore the role of religion in the stigmatization of PWHA by nurses in Puerto Rico. We conducted an exploratory study using qualitative techniques. We conducted 40 in-depth interviews with nurses who provided services to PWHA. Three main factors emerged in the analysis as contributors to HIV/AIDS stigmatization: (1) nurses' personal religious experiences, (2) religion as a rationale for HIV-related stigma, and (3) religious practices during health care delivery. The results show that religious beliefs play a role in how nurses understood HIV/AIDS and provided service. Results point toward the need for interventions that address personal religious beliefs while reducing HIV/AIDS stigma among nurses.

Prevalence and Incidence of Anxiety and Depression Among Children, Adolescents, and Young Adults With Life-Limiting Conditions: A Systematic Review and Meta-analysis

IMPORTANCE

Children, adolescents, and young adults with life-limiting conditions experience various challenges that may make them more vulnerable to mental health problems, such as anxiety and depression. However, the prevalence and incidence of anxiety and depression among this population appears to be unknown.

OBJECTIVE

To conduct a systematic review and meta-analysis to estimate the prevalence and/or incidence of anxiety and depression in children, adolescents, and young adults with life-limiting conditions.

DATA SOURCES

Searches of MEDLINE (PubMed), PsycInfo, and Embase were conducted to identify studies published between January 2000 and January 2018.

STUDY SELECTION

Studies were eligible for this review if they provided primary data of anxiety or depression prevalence and/or incidence, included participants aged 5 to 25 years with a life-limiting condition, were conducted in an Organisation for Economic Co-operation and Development country, and were available in English.

DATA EXTRACTION AND SYNTHESIS

Random-effects meta-analyses were generated to provide anxiety and depression prevalence estimates. Meta-regression was conducted to analyze associations between study characteristics and each prevalence estimate.

MAIN OUTCOMES AND MEASURES

Prevalence of anxiety and depression.

RESULTS

A total of 14 866 nonduplicate articles were screened, of which 37 were included in the review. Of these, 19 studies reported anxiety prevalence, and 36 studies reported depression prevalence. The mean (range) age of participants was 15.4 (6-25) years. The meta-analysis of anxiety prevalence (n = 4547 participants) generated a pooled prevalence estimate of 19.1% (95% CI, 14.1%-24.6%). Meta-regression analysis found statistically significant differences in anxiety prevalence by assessment tool; diagnostic interviews were associated with higher anxiety prevalence (28.5% [95% CI, 13.2%-46.8%]) than self-reported or parent-reported measures (14.9% [95% CI, 10.9%-19.4%]). The depression meta-analysis (n = 5934 participants) found a pooled prevalence estimate of 14.3% (95% CI, 10.5%-18.6%). Meta-regression analysis revealed statistically significant differences in depression prevalence by the mean age of the sample (β = 0.02 [95% CI, 0.01-0.03]; P = .001).

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, the prevalence of anxiety and depression among children, adolescents, and young adults with life-limiting conditions was high, highlighting the need for increased psychological assessment and monitoring. Further research is required to determine the prevalence and incidence of anxiety and depression in a larger sample of children, adolescents, and young adults with a broader range of life-limiting conditions.

Measuring Antiretroviral Adherence Among Young People Living with HIV: Observations from a Real-Time Monitoring Device Versus Self-report

This report compares self-report (SR) antiretroviral (ARV) adherence data to adherence data collected via Wisepill, a real-time electronic monitoring (EM) device, among young people living with HIV (YPLH) in the southern United States. Participants (n = 66; ages 16 to 26) were followed for 14 weeks. Descriptive analyses were used to compare SR to EM data. Correlations and a linear regression were conducted to explore factors possibly associated with SR-EM discrepancies. We also examined associations between various levels of SR and EM adherence and viral suppression/non-suppression at 14 weeks. Rates of SR adherence were maintained between 87% and 92% while rates of EM adherence declined from 64% to 34%. YPLH who were ARV-experienced, had lower treatment motivation, and reported more frequent recent marijuana use, had a greater discrepancy between their SR and EM adherence levels compared to other YPLH. Higher rates of SR and EM adherence were independently associated with a decline in viral load. A sensitivity analysis also revealed that SR adherence was a better predictor of viral non-suppression, whereas EM adherence was a better predictor of viral suppression. These measurement approaches are discussed in the context of providing clinical care to YPLH.

Psychological resilience among transfeminine adolescents and emerging adults living with HIV

OBJECTIVES

The current study sought to examine factors that promote psychological resilience related to engagement in the HIV continuum of care (CoC) among transfeminine adolescents and emerging adults (TF AEA) living with HIV in the U.S. using a qualitative approach.

DESIGN

The parent study from which these data came utilized a concurrent transformative mixed-methods research design grounded in Gender Affirmation and Gender Minority Stress Theory that focused on advancing our understanding of transgender youth's experiences with healthcare generally and their experiences across the HIV CoC.

METHODS

Semi-structured in-depth qualitative interviews with 66 TF AEA living with HIV were analysed using a two-stage interpretive phenomenological analytic approach that allowed for both inductive and deductive explorations of the data.

RESULTS

When discussing health-promoting psychological resilience factors, participants described both interpersonal resources (i.e. support or assistance via interactions with others) and intrapersonal assets (i.e. positive internal cognitive processes) that encouraged their engagement in the HIV CoC. The interpersonal resources described by participants included three main types of support: emotional support, gender support and instrumental-informational support. Three thematic categories describe the intrapersonal assets that participants discussed: health awareness and HIV acceptance; health motivation and health responsibility; and psychological well being and inner strength.

CONCLUSION

Despite experiences of HIV-related stigma and transphobia, TF AEA living with HIV demonstrate psychological resilience, as they navigate engagement in the HIV CoC. Results highlight possibilities for implementing public health interventions at individual, community and systems levels to bolster resilience among TF AEA living with HIV.

Experienced HIV-Related Stigma and Psychological Distress in Peruvian Sexual and Gender Minorities: A Longitudinal Study to Explore Mediating Roles of Internalized HIV-Related Stigma and Coping Styles

Experiencing HIV-related stigma has important impacts on the mental health of people living with HIV, which has implications for treatment adherence, disease progression, and health outcomes. The impacts of stigma are particularly important to consider among sexual and gender minorities, who often face a disproportionate burden of HIV. To address the implications of stigma in these key populations, we leveraged a longitudinal study conducted among Peruvian sexual and gender minorities to compare the relative effects of multiple mediators affecting the relationship between experienced HIV-related stigma and psychological distress: internalized HIV-related stigma, adaptive coping, and maladaptive coping. HIV-related stigma, coping, and distress were measured, respectively, at 24 weeks, 36 weeks, and 48 weeks post-diagnosis for 145 participants from the Sabes Study. HIV-related maladaptive coping largely mediated the relationship between experienced HIV-related stigma and distress. Our findings suggest interventions targeting maladaptive coping may alleviate the mental health consequences of experiencing HIV-related stigma.

The Supporting Adolescent Adherence in Vietnam (SAAV) study: study protocol for a randomized controlled trial assessing an mHealth approach to improving adherence for adolescents living with HIV in Vietnam

BACKGROUND

The overall goal of the Supporting Adolescent Adherence in Vietnam (SAAV) study is to improve understanding of an adherence feedback mHealth intervention designed to help adolescents living with HIV (ALHIV) maintain high adherence to antiretroviral therapy (ART), critical to effective treatment. Specifically, we aim to: (1) conduct formative research with Vietnamese ALHIV and their caregivers to better understand adherence challenges and refine the personalized mHealth intervention package; and (2) assess the feasibility, acceptability, and efficacy of the intervention to improve ART adherence by implementing a randomized controlled trial (RCT).

METHODS

The study will utilize mixed methods. The formative phase will include 40 in-depth interviews (IDIs) with 20 adolescent (12-17 years)/caregiver dyads and eight focus group discussions with adolescents, caregivers, and clinicians at the National Hospital for Pediatrics (NHP) in Hanoi, Vietnam. We will also conduct 20 IDIs with older adolescents (18-21 years) who have transitioned to adult care at outpatient clinics in Hanoi. We will then implement a seven-month RCT at NHP. We will recruit 80 adolescents on ART, monitor their adherence for one month to establish baseline adherence using a wireless pill container (WPC), and then randomize participants to intervention versus control within optimal (≥ 95% on-time doses) versus suboptimal (< 95% on-time doses) baseline adherence strata. Intervention participants will receive a reminder of their choice (cellphone text message/call or bottle-based flash/alarm), triggered when they miss a dose, and engage in monthly counseling informed by their adherence data. Comparison participants will receive usual care and offer of counseling at routine monthly clinic visits. After six months, we will compare ART adherence, CD4 count, and HIV viral suppression between arms, in addition to acceptability and feasibility of the intervention.

DISCUSSION

Findings will contribute valuable information on perceived barriers and facilitators affecting adolescents' ART adherence, mHealth approaches as adherence support tools for ALHIV, and factors affecting adolescents' ART adherence. This information will be useful to researchers, medical personnel, and policy-makers as they develop and implement adherence programs for ALHIV, with potential relevance to other chronic diseases during transition from adolescent to adult care.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03031197 . Registered on 21 January 2017.

Enhancing health among youth living with HIV using an iPhone game

BACKGROUND

Despite promising outcomes of antiretroviral therapy (ART), challenges to improving adherence among youth living with HIV (YLWH) exist. Mobile games are popular among youth and may improve skills related to resilience, coping, and ART adherence. This study examines the preliminary effects of an iPhone game/app on ART adherence, viral load, and relevant knowledge and attitudes among YLWH in Jackson, MS.

METHODS

A RCT with 61 YLWH tested the impact of BattleViro, an ART-related iPhone game, over 16 weeks. Participants, ages 14-26, were recruited from HIV clinics and randomly assigned to receive BattleViro or a non-HIV-related game. All participants received a medication monitoring device. Chi-square and t-test analyses examined baseline differences between conditions. Continuous outcomes were examined using analyses of covariance (ANCOVAs) controlling for baseline scores. Cohen's d effect size differences (ESD) between groups were calculated.

RESULTS

The sample was 79% male, 97% Black, and 74% non-heterosexual, with a mean age of 22 years. A third had started ART in the past 3 months. There were no demographic differences between conditions. Examination of ESDs revealed that BattleViro demonstrated promising, but nonsignificant, improvements in HIV knowledge (ESD = 0.50), ART knowledge (ESD = 0.42) and social support (ESD = 0.62). Exploratory moderation analyses revealed interactions between BattleViro and newly starting ART. Those newly starting ART in the BattleViro condition, compared to those in the control, experienced a 0.96 log greater decrease in viral load (ESD=-2.21, F = 4.33, p = 0.04), better adherence (71% vs. 48%; ESD = 1.15, F = 3.90, p = 0.05), more HIV knowledge (ESD = 0.90), and more ART knowledge (ESD = 0.72).

CONCLUSION

BattleViro showed promising improvements in HIV knowledge, ART knowledge and social support. Also, there was improved adherence and viral load outcomes specifically among those newly starting ART. ART initiation may be an opportunity to empower and motivate YLWH to build healthy skills.

Prevalence of Depressive Symptoms and Associated Factors among HIV-Positive Youth Attending ART Follow-Up in Addis Ababa, Ethiopia

Depression is most frequently and highly occurring common mental disorder in HIV/AIDS patients especially youth living with HIV/AIDS. This study aimed to assess the prevalence and associated factors of depressive symptoms among youth living with Human Immunodeficiency Virus (HIV) attending Antiretroviral Therapy (ART) follow-up at public hospitals in Addis Ababa, Ethiopia. Objective. To assess the prevalence and associated factors of depressive symptoms among youth living with Human Immunodeficiency Virus (HIV) attending Antiretroviral Therapy (ART) follow-up at public hospitals Addis Ababa, Ethiopia, 2016. Method. In a cross sectional study, 507 HIV-positive young people from public health hospitals were recruited by systematic random sampling technique. Beck Depression Inventory-II was used to assess depressive symptoms. Morisky medication adherence rating scale, social support rating scale, and HIV stigma scale were the instruments used to assess the associated factors. Results. Prevalence of depressive symptoms among HIV-positive youth was 35.5% (95% CI:31.3, 39.6). In multivariate analysis, age range between 20 and 24 years with (AOR=2.22, 95% CI: 1.33,3.62), history of opportunistic infection (AOR=1.94, 95% CI:1.15,3.27), poor medication adherence (AOR=1.73, 95%CI:1.13,2.64, low social support (AOR=2.74, 95%CI:1.13,2.64), moderate social support (AOR=1.75 95% CI: 1.03,2.98), and stigma (AOR=2.06, 95% CI: 1.35,3.14) were associated with depressive symptoms. The results suggest that prevalence of depressive symptoms among HIV-positive youth was high. Prevention of opportunistic infection, stigma, and counseling for good medication adherence are necessary among HIV-positive youth.

[MOBILE TECHNOLOGY AS A POTENTIAL TOOL IN RESEARCH ON STIGMA ASSOCIATED WITH HIV/AIDS AMONG MEDICAL STUDENTS]

The identification and reduction of manifestations of stigma associated with HIV/ AIDS among health professionals continues facing significant challenges. Some of these are the measurement of stigma in complex setting such as clinical scenarios. However, with the emergence of mobile technology in recent years, such as smartphones and tablets, possibilities for exploration and reduction of stigma manifestations are enhanced. This article aims to reflect on the ability of the iPad to help assess manifestations of stigma associated with HIV/AIDS within a controlled clinical setting with medical students. It is based on a research experience that was carried out to measure behavioral manifestations of stigma associated with HIV/AIDS among medical students in Puerto Rico. The study integrated the use of iPad in the data's collection, storage and analysis. This article highlights the use of existing applications (Apps) for iPad for the implementation of digital tools to measure stigma towards HIV/AIDS. In discussing the experience of researchers, the iPad's potential and it applications for research on stigma are highlighted. Also, implications for the use of mobile technology in social research are discussed.

Critical Consciousness-Based HIV Prevention Interventions for Black Gay and Bisexual Male Youth

Black gay/bisexual male youth are one of the groups most affected by HIV in the U.S., but few behavioral interventions have been created specifically to address this health inequity. Oppression related to these youths' multiple social identities - including racism, heterosexism, and HIV stigma - contribute to increased health risks. Primary and secondary HIV prevention interventions created specifically for Black gay/bisexual male youth that address the negative impact of oppression are urgently needed. We present empowerment as a framework for understanding how oppression affects health, and critical consciousness as a tool to be utilized in behavioral interventions. This approach helps to move Black gay/bisexual male youth from a place of oppression and powerlessness that leads to elevated health risks to a position of empowerment that promotes feelings of control and participation in healthy behaviors. Finally, we present a case example of our own critical consciousness-based secondary HIV prevention intervention created specifically for Black gay/bisexual male youth.

Characteristics of adolescents living with HIV receiving care and treatment services in antiretroviral therapy clinics in Cambodia: descriptive findings from a cross-sectional study

Background

Adolescents living with HIV experience worse HIV care outcomes compared to adults, especially during transition from pediatric to adult care. However, data regarding adolescents are limited. This paper describes and compares characteristics of male and female adolescents living with HIV preparing for transition from pediatric to adult care in Cambodia.

Methods

This cross-sectional study was conducted in August 2016 among 328 adolescents aged 15–17, randomly selected from 11 antiretroviral therapy (ART) clinics. Data were collected using a structured questionnaire, and descriptive analyses were conducted to compare characteristics of male and female adolescents.

Results

Of total, 55.2% were male, and 40.8% were living with parents. Majority (82.6%) got HIV infection from their mothers. Overall, adolescents had received ART for an average of 8.4 years, and HIV care for 9.5 years. Additionally, 82.4% were on first line ART regimen. Mean CD4 count from the most recent test was 672 cells/mm³, and viral load was 7686 copies/mL. Overall, 95.6% were adherent to ART on Visual Analogue Scale. About half (50.7%) had never disclosed their HIV status to anyone, while the remaining had disclosed it to their siblings (24.2%), friends (13.0%), schoolteachers (2.4%), or other (5.8%). A fifth reported having had boy or girlfriends, but few (2.1%) had ever had sexual intercourse. Females were more likely to have been engaged in sexual intercourse, and none reported having used a condom in their last intercourse. Few participants reported having ever used tobacco (1.8%), or any kind of illicit drugs (0.9%), but almost a fifth (20.7%) had a history of alcohol use. The majority (82.1%) were aware that they were receiving ART. HIV-related knowledge was suboptimal among the sample.

Conclusions

This study provides a snapshot of immunological, virological, adherence, and disclosure outcomes that should be tracked during and following healthcare transition to evaluate the effectiveness of the transition program. Findings showed high ART adherence, low likelihood of disclosure outside of family circles, sub-optimal condom use, and poor knowledge of HIV. To provide individualized support for healthcare transition, pediatric and adult clinics need to ensure that these characteristics are taken into account.

Racial and socioeconomic disparities in the symptom reporting of persons living with HIV

Persons living with HIV (PLWH) today can survive decades with the disease, making the symptom experience much more relevant to their lifestyle and health outcomes. The goal of the research reported here was to assess the symptom reporting of PLWH in the Unites States (US) in the combined antiretroviral therapy (cART) age of the epidemic. We conducted an anonymous online survey of symptomatic PLWH in the US and asked participants to report the frequency and intensity of 28 frequently occurring symptoms in the past 30 days. The relationship between symptom reporting and demographic factors was investigated using the adaptive least absolute shrinkage and selection operator (LASSO) method. Fatigue was the most frequently reported symptom in our study population. Those with the lowest income were more likely to report more burdensome symptoms. In comparison to other racial and ethnic groups, Black non-Hispanic participants were significantly more likely to report a lower symptom burden score for fatigue, depression, muscle aches, anxiety, difficulties with memory and concentration. There were no racial/ ethnic differences in the burden of the symptoms related to sleep or neuropathy. Findings from this study present new evidence on the symptom reporting of PLWH in the US. Neuropathy continues to be a pervasive neurological symptom with no difference noted between racial/ ethnic groups.

The Clinic Environment as a Form of Social Support for Adolescents and Young Adults Living with HIV

Adolescents and young adults living with HIV (YLHIV) face numerous stresses that affect their care and medication adherence. The clinic social environment may play an important supportive role for YLHIV, influencing health outcomes. The aim of this article is to explore how YLHIV in Baltimore, Maryland understand the various forms of social support provided within the social environment of their HIV clinic. We used qualitative research methods including iterative, semi-structured in-depth interviews with 20 YLHIV interviewed up to three times each to explore HIV stressors, support systems, and medication adherence. We employed thematic content analysis to systematically code and synthesize textual interview data. We found that YLHIV experienced social embeddedness with their healthcare teams and through clinic activities. Participants largely perceived these social connections as support, acknowledging that these supports are available to them when needed. Support was enacted through the provision of instrumental support for issues outside of the young person's medical care (i.e., finding a crib for a participant's baby), appraisal (i.e., through respect of the young person's agency and decision making), and information about their HIV care and medication. Support was not always well received, however, as some young people found the support from clinicians demeaning. Limitations of the clinic social support environment included concerns about trust and privacy, and perceiving support as inappropriate or unwanted. Participants identified a number of ways in which the clinic provided meaningful social support. Future research should explore how these supports may improve care and medication adherence of YLHIV.

Psychological well-being and adherence to antiretroviral therapy among adolescents living with HIV in Zambia

Physical and psychosocial changes during adolescence could influence the psychological well-being and adherence to antiretroviral therapy (ART) of adolescents living with HIV. However, few studies have assessed these two important issues in Zambia. This study aimed at addressing this gap by examining adolescents' depressive symptoms and ART adherence. This was a mixed-methods study conducted from April to July 2014. We recruited 200 adolescents, ages 15 to 19, who were already aware of their HIV status. We measured depressive symptoms using the short form of the Center for Epidemiologic Studies Depression Scale, and self-reported three-day adherence to ART. We performed logistic regression analysis to identify factors associated with depressive symptoms and non-adherence to ART. For qualitative data, we examined challenges over ART adherence using thematic analysis. Out of 190 adolescents, 25.3% showed high scores of depressive symptoms. Factors associated with depressive symptoms were unsatisfactory relationships with family (Adjusted Odds Ratio [AOR] 3.01; 95% Confidence Interval [CI] 1.20-7.56); unsatisfactory relationships with health workers (AOR 2.68; 95% CI 1.04-6.93); and experience of stigma (AOR 2.99; 95% CI 1.07-8.41). Of all participants, 94.2% were taking ART, but 28.3% were non-adherent. Factors associated with non-adherence to ART were loss of a mother (AOR 3.00; 95% CI 1.05-8.58) and lack of basic knowledge about HIV (AOR 3.25; 95% CI 1.43-7.40). Qualitative data identified the following challenges to ART adherence: management of medication, physical reactions to medicine, and psychosocial distress. The evidence suggests that depressive symptoms and non-adherence to ART were priority issues in late adolescence in Zambia. Health workers should be aware of these issues, and the care and treatment services should be tailored to respond to age-specific needs.

Religious and spiritual coping in people living with HIV/Aids

OBJECTIVE

evaluate the religiosity and the religious/spiritual coping of people living with HIV/Aids.

METHOD

descriptive, cross-sectional study with quantitative approach, conducted in a reference HIV/Aids outpatient clinic in a university hospital of Recife-PE, Brazil, from June to November 2015. At total of 52 people living with HIV/Aids (PLWHA) participated in the research, which employed own questionnaire, the Duke University Religion Index (DUREL), and the Religious/Spiritual Coping Scale (RCOPE).

RESULTS

the sample presented high indices of organizational religiosity (4.23±1.66), non-organizational religiosity (4.63±1.50), and intrinsic religiosity (13.13±2.84). Positive RCOPE was used in high mean scores (3.66±0.88), and negative RCOPE had low use (2.12 ± 0.74). In total, use of RCOPE was high (3.77±0.74), having predominated the positive RCOPE (NegRCOPE/PosRCOPE ratio=0.65±0.46).

CONCLUSION

it is evident the importance of encouraging religious activity and RCOPE strategies, seen in the past as inappropriate interventions in clinical practice.

The case for viral load testing in adolescents in resource-limited settings

INTRODUCTION

The success of HIV treatment programmes globally has resulted in children with perinatally acquired HIV reaching adolescence in large numbers. The number of adolescents living with HIV is growing further due to persisting high HIV incidence rates among adolescents in low- and middle-income settings, particularly in sub-Saharan Africa. Although expanding access to HIV viral load monitoring is necessary to achieve the 90-90-90 targets across the HIV care continuum, implementation is incomplete. We discuss the rationale for prioritizing viral load monitoring among adolescents and the associated challenges.

DISCUSSION

Adolescents with HIV are a complex group to treat successfully due to extensive exposure to antiretroviral therapy for those with perinatally acquired HIV and the challenges in sustained medication adherence in this age group. Given the high risk of treatment failure among adolescents and the limited drug regimens available in limited resource settings, HIV viral load monitoring in adolescents could prevent unnecessary and costly switches to second-line therapy in virologically suppressed adolescents. Because adolescents living with HIV may be heavily treatment experienced, have suboptimal treatment adherence, or may be on second or even third-line therapy, viral load testing would allow clinicians to make informed decisions about increased counselling and support for adolescents together with the need to maintain or switch therapeutic regimens.

CONCLUSIONS

Given scarce resources, prioritization of viral load testing among groups with a high risk of virological failure may be required. Adolescents have disproportionately high rates of virological failure, and targeting this age group for viral load monitoring may provide valuable lessons to inform broader scale-up.