Depression and Anxiety as Risk Factors for Delayed Care-Seeking Behavior in Human Immunodeficiency Virus-Infected Individuals in South Africa

Impact of training healthcare professionals in the detection and management of neuropsychiatric comorbidities in people with HIV: The CONECTAR project in Spain

INTRODUCTION

Although anxiety, depression and insomnia in people with HIV (PWH) are prevalent and have a major impact on clinical outcomes and quality of life, physicians fail to evaluate them routinely. The CONECTAR Project [Neuropsychiatric Comorbidity (NPC): Key to Antiretroviral Treatment] aimed to improve NPC clinical care in PWH in Spain by upskilling healthcare professionals (HCPs).

METHODS

A group of HCPs developed a training programme, supported by national and international guidelines, to improve expertise on detecting and managing NPCs in PWH. The programme was conducted through workshops for physicians and nurses in various Spanish regions from April to November 2023; survey questionnaires were administered to physicians before the commencement of training and 15 days after. Later, a workshop was held for nurses who manage NPCs in PWH.

RESULTS

The programme was completed by 64 physicians (22 had completed both questionnaires) and 11 nurses (no feedback obtained). Feedback from physicians reflected that the programme boosted awareness and self-perception of being more qualified, knowledgeable and able to use management tools and resources. Physicians also reported improved perception of time available for visits and more frequent enquiries about patients' NPC symptoms. Despite their satisfaction with the workshops, half of the physicians recognized the need for more training.

CONCLUSION

The CONECTAR Project was a successful training programme that was well received and valued by HCPs who routinely manage NPCs in PWH. Institutions involved in HCP training to manage anxiety, depression and insomnia more effectively in PWH should consider similar proposals to reinforce clinical practices.

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.

Prevalence and co-occurrence of symptoms of mental and substance use disorders among people with HIV age 40 and older in low- and middle-income countries: a cross-sectional study

INTRODUCTION

Due to the increased effectiveness of and access to antiretroviral therapy (ART), people with HIV (PWH) are living longer. As a result, the population of older PWH has increased. Mental and substance use disorders (MSDs) are common and frequently co-occurring among PWH and are associated with poor HIV care outcomes. Research into the prevalence and co-occurrence of MSDs among ageing PWH remains limited, particularly in low- and middle-income countries (LMICs).

METHODS

We analysed data collected between 2020 and 2022 from the International epidemiology Databases to Evaluate AIDS (IeDEA) Sentinel Research Network cohort of PWH aged 40 years or older on ART at 11 HIV clinics in Brazil, Côte d'Ivoire, India, Kenya, Mexico, Uganda, Rwanda, Togo, Vietnam, Zambia and Zimbabwe. We estimated the prevalence and co-occurrence of unhealthy alcohol use (AUDIT-C ≥3 for women, ≥4 for men), unhealthy drug use (ASSIST >3 for cannabis, cocaine, amphetamines, inhalants, sedatives, hallucinogens and/or opioids), and moderate to severe symptoms of depression (PHQ-9 ≥10), anxiety (GAD-7 ≥10) and post-traumatic stress disorder (PTSD) (PCL-5 ≥33). Psychiatric multimorbidity was defined as having symptoms of two or more disorders assessed. Log binomial models assessed the association between socio-demographic and HIV care characteristics and symptoms of anxiety, depression, PTSD or unhealthy substance use.

RESULTS

Of 2821 participants, the prevalence of unhealthy alcohol and drug use was 21% and 5%, respectively. The prevalence of moderate to severe symptoms of depression, anxiety and PTSD was 14%, 9% and 6%, respectively. Overall, the prevalence of psychiatric multimorbidity was 11%. Among those with symptoms of at least one mental health or substance use outcome assessed (n = 1036), the prevalence of psychiatric multimorbidity was 31%. In binomial models, the prevalence of symptoms of depression and anxiety was higher, while the prevalence of unhealthy alcohol and drug use was lower among women than men.

CONCLUSIONS

Unhealthy alcohol use and symptoms of depression were most commonly reported, among this cohort of PWH aged 40 or older across 11 LMICs. Integration of MSD screening and treatment into HIV care should be prioritized. The effectiveness and implementation of transdiagnostic or multi-focus mental health treatment approaches in HIV care settings should be examined.

Optimizing generalized anxiety disorder screening in young adults perinatally affected by HIV: A psychometric analysis

Background

Generalized Anxiety Disorder (GAD) is prevalent among people with HIV and is associated with adverse health outcomes. This study investigates the suitability of the Generalized Anxiety Disorder Scale-7 item (GAD-7) screening tool and its 2-item (GAD-2) version for use in young adults with perinatally-acquired HIV (YAPHIV) and young adults perinatally exposed to HIV but uninfected (YAPHEU).

Methods

Data come from the 7th follow-up interview (FU7) from a longitudinal study of youth with PHIV and PHEU, first recruited when 9-16 years. The GAD-7 was administered along with a diagnostic psychiatric interview (DISC-IV). Receiver Operating Characteristic analysis assessed accuracy, sensitivity, and specificity of the GAD7 and GAD-2. Subgroup analyses considered HIV status, ethnicity, and race.

Results

At FU7, participants (n = 204) were ages 20-29; 54% female; and the majority African-American and/or Latinx. 12% met diagnostic criteria for GAD. Recommended GAD-7 (>10) and GAD-2 (>3) cut-scores showed suboptimal sensitivity (0.52 and 0.48, respectively) and high specificity (0.91 and 0.90, respectively). Lowering cut-scores (GAD-7 >6 and GAD-2 >2) improved sensitivity (0.76 and 0.80) while sacrificing specificity (0.77 and 0.78). Stratified analyses by HIV status revealed similar accuracy in YAPHIV and YAPHEU. Race/ethnicity did not significantly affect cut-scores.

Discussion

Anxiety disorders are common in YAPHIV, and efficient screening is essential. While the GAD-7 and GAD-2 show promise, recommended cut-scores may not be optimal. Lowering cut-scores may enhance sensitivity without losing clinical utility. Further research is needed to refine cut-scores based on demographic characteristics and in global contexts, ensuring effective anxiety screening in this population.

Yasin M, Mat Nasir N, Mohamad M. The association between HIV-related stigma, HIV knowledge and HIV late presenters among people living with HIV (PLHIV) attending public primary care clinic settings in Selangor

INTRODUCTION

HIV late presenters were defined as individuals presenting with a CD4 count below 350 cells/μL or with an AIDS-defining event, according to the European Late Presenter Consensus working group. Early diagnosis and treatment of HIV have proven beneficial for people living with HIV (PLHIV), reducing the burden on healthcare systems, and contributing to ending the HIV/AIDS epidemic. However, in Malaysia, over 50% of newly diagnosed HIV patients present late, leading to increased morbidity and premature mortality. This study aims to determine the prevalence of late HIV presenters and its association with HIV-related stigma and HIV knowledge among PLHIV attending public primary care clinics in Selangor.

METHODS

A cross-sectional study was conducted at selected public health clinics in Selangor, involving PLHIV aged 18 years and older, who were diagnosed since 2019. HIV-related stigma was measured using the Malay version of Berger's HIV Stigma Scale, and HIV knowledge was assessed using the Malay version of Brief HIV-KQ-18. Univariate and multivariate logistic regression analyses were performed to identify factors associated with late HIV presentation.

RESULTS

A total of 400 participants were included in the study, with 60.0% (n = 240, 95% CI: 55.0-65.0) classified as late presenters. The participants had a mean age of 30.29 (±7.77) years. The risk factors for late presenters were high levels of HIV-related stigma (aOR = 1.049, 95% CI: 1.034-1.063, p-value <0.001), low levels of HIV knowledge (aOR = 0.709, 95% CI: 0.646-0.778, p-value <0.001), tertiary education background (aOR = 15.962, 95% CI: 1.898-134.235, p-value = 0.011), and being single (aOR = 3.582, 95% CI: 1.393-9.208, p-value = 0.008).

CONCLUSION

This study highlights the association between high levels of HIV-related stigma, low levels of HIV knowledge, and late HIV presentation. Interventions targeting stigma reduction and HIV education can promote early testing and prompt access to care, improving health outcomes for PLHIV.

Patient Perspectives on Portal-Based Anxiety and Depression Screening in HIV Care: A Qualitative Study Using the Consolidated Framework for Implementation Research

Electronic patient portals represent a promising means of integrating mental health assessments into HIV care where anxiety and depression are highly prevalent. Patient attitudes toward portal-based mental health screening within HIV clinics have not been well described. The aim of this formative qualitative study is to characterize the patient-perceived facilitators and barriers to portal-based anxiety and depression screening within HIV care in order to inform implementation strategies for mental health screening. Twelve adult HIV clinic patients participated in semi-structured interviews that were audio recorded and transcribed. The transcripts were coded using constructs from the Consolidated Framework for Implementation Research and analyzed thematically to identify the barriers to and facilitators of portal-based anxiety and depression screening. Facilitators included an absence of alternative screening methods, an approachable design, perceived adaptability, high compatibility with HIV care, the potential for linkage to treatment, an increased self-awareness of mental health conditions, the ability to bundle screening with clinic visits, and communicating an action plan for results. The barriers included difficulty navigating the patient portal system, a lack of technical support, stigmatization from the healthcare system, care team response times, and the novelty of using patient portals for communication. The patients in the HIV clinic viewed the use of a portal-based anxiety and depression screening tool as highly compatible with routine HIV care. Technical difficulties, follow-up concerns, and a fear of stigmatization were commonly perceived as barriers to portal use. The results of this study can be used to inform implementation strategies when designing or incorporating portal-based mental health screening into other HIV care settings.

"I've accepted it because at the end of the day there is nothing, I can do about it": A qualitative study exploring the experiences of women living with the HIV, intimate partner violence and mental health syndemic in Mpumalanga, South Africa

In South Africa, Mental Health (MH), HIV, and Intimate Partner Violence (IPV) form a syndemic, that disproportionately affects women. These challenges are often co-occurring and create complex adversities for women. Recognising these intersections and the broader socio-cultural dynamics at play is crucial to understanding the layered experiences of these women and developing effective interventions. This research explores the experiences of the women living with at least two of the epidemics (HIV, IPV and or MH) and how they cope. A qualitative study design was used and 20 women (22-60 years) were recruited from Mpumalanga, South Africa. To be eligible for the study the women had to have experienced at least two of the epidemics. Data were collected through home-based interviews, arts-based activities, and analysed thematically using MAXQDA (2022) software. MH challenges were prevalent among all the participants and were linked to both IPV and HIV, resulting in symptoms such as anxiety, depression, and suicidal thoughts. In relation to the HIV-MH link, MH challenges in this combination included feelings of denial, sadness and anxiety related to participant's HIV diagnosis. A bidirectional relationship also existed in the IPV-MH group where pre-existing MH challenges among women increased their vulnerability of having violent partners, whilst IPV also increased MH challenges. In the IPV-MH-HIV group early childhood violence exposure was linked with MH challenges and later victimization and vulnerability to HIV. Participants primarily used religion, acceptance, occasional alcohol, and family support as coping strategies. Particularly in IPV situations, alcohol use/misuse was the most prevalent coping strategies. The study highlights the syndemic relationship between HIV, IPV and MH challenges among South African women living in a peri-urban community, with a central emphasis on MH challenges. Interventions should holistically address these challenges, with particular focus on MH challenges, cultural sensitivity, and promotion of healthy coping strategies.

The longitudinal association of stressful life events with depression remission among SHARP trial participants with depression and hypertension or diabetes in Malawi

Depressive disorders are leading contributors to morbidity in low- and middle-income countries and are particularly prevalent among people with non-communicable diseases (NCD). Stressful life events (SLEs) are risk factors for, and can help identify those at risk of, severe depressive illness requiring more aggressive treatment. Yet, research on the impact of SLEs on the trajectory of depressive symptoms among NCD patients indicated for depression treatment is lacking, especially in low resource settings. This study aims to estimate the longitudinal association of SLEs at baseline with depression remission achievement at three, six, and 12 months among adults with either hypertension or diabetes and comorbid depression identified as being eligible for depression treatment. Participants were recruited from 10 NCD clinics in Malawi from May 2019-December 2021. SLEs were measured by the Life Events Survey and depression remission was defined as achieving a Patient Health Questionaire-9 (PHQ-9) score <5 at follow-up. The study population (n = 737) consisted predominately of females aged 50 or higher with primary education and current employment. At baseline, participants reported a mean of 3.5 SLEs in the prior three months with 90% reporting ≥1 SLE. After adjustment, each additional SLE was associated with a lower probability of achieving depression remission at three months (cumulative incidence ratio (CIR) 0.94; 95% confidence interval: 0.90, 0.98, p = 0.002), six months (0.95; 0.92, 0.98, p = 0.002) and 12 months (0.96; 0.94, 0.99, p = 0.011). Re-expressed per 3-unit change, the probability of achieving depression remission at three, six, and 12 months was 0.82, 0.86, and 0.89 times lower per 3 SLEs (the median number of SLEs). Among NCD patients identified as eligible for depression treatment, recent SLEs at baseline were associated with lower probability of achieving depression remission at three, six, and 12 months. Findings suggest that interventions addressing SLEs during integrated NCD and depression care interventions (e.g., teaching and practicing SLE coping strategies) may improve success of depression treatment among adult patient populations in low-resource settings and may help identify those at risk of severe and treatment resistant depression.

HIV Treatment and Mental Health Outcomes Among Gay, Bisexual, and Other Men Who Have Sex With Men Living With HIV in a Pilot Multicomponent Intervention in Guatemala City

Globally, gay, bisexual, and other men who have sex with men (GBMSM) are disproportionately affected by HIV, but few interventions address mental health and HIV outcomes among GBMSM living with HIV. The purpose of this study was to pilot a multicomponent intervention, integrating emotional well-being (EW) and health navigation for GBMSM living with HIV in Guatemala City. We implemented a 12-month intervention, including a four-session EW component and a health navigation component among newly diagnosed and reengaged GBMSM with HIV (n = 112). We conducted socio-behavioral surveys at baseline and endline to measure patient characteristics and HIV, and mental health outcomes as well as viral load testing. We documented participation in EW sessions and used a smartphone application to track navigation mode, frequency, and content. Using first-difference estimation modeling, we assessed associations between participation in EW and navigation and mental health (depression and anxiety symptoms) and HIV outcomes (HIV treatment adherence, viral suppression). Acceptability was high for EW (86%) and navigation (99%). During the intervention, viral suppression increased significantly and anxiety and depression decreased significantly. Participation in EW sessions and greater navigation frequency and duration were associated with being suppressed, whereas higher emotional navigator support was associated with being unsuppressed. Participation in EW sessions was associated with reduced anxiety. Findings suggest that multicomponent interventions integrating individual counseling and navigation may promote EW and sustained viral suppression. Future intervention research is needed to confirm whether HIV and mental health outcomes are attributable to the intervention and to assess mechanisms of influence.

Depression and HIV Care-seeking Behaviors in a Population-based Sample in North West Province, South Africa

Depression is associated with key HIV-related prevention and treatment behaviors in sub-Saharan Africa. We aimed to identify the association of depressive symptoms with HIV testing, linkage to care, and ART adherence among a representative sample of 18-49 year-olds in a high prevalence, rural area of South Africa. Utilizing logistic regression models (N = 1044), depressive symptoms were inversely associated with reported ever HIV testing (AOR 0.92, 95% CI 0.85-0.99; p = 0.04) and ART adherence (AOR 0.82, 95% CI: 0.73-0.91; p < 0.01) among women. For men, depressive symptoms were positively associated with linkage to care (AOR: 1.21, 95% CI: 1.09-1.34; p < 0.01). Depression may adversely impact ART adherence for HIV-positive women and reduce the likelihood of HIV testing for women not aware of their HIV status which, in settings with high HIV prevalence, carries severe consequences. For HIV-positive men, findings suggest that depression may encourage help-seeking behavior, thereby impacting their health system interactions. These findings underscore the need for health-care settings to factor mental health, such as depression, into their programs to address health-related outcomes, particularly for women.

Identifying Psychological Perceptions of People Ignoring the Novel COVID-19 Warnings: A Qualitative Thematic Analysis in Isfahan, Iran

Psychological factors are important for the prevention of disease. This study aims to identify the psychological perceptions of people who are ignoring the warnings of novel COVID-19 infection. A qualitative content analysis was carried out from May to July 2020. The interviewees were selected purposefully from Isfahan, Iran. The saturation point was achieved in 20 semi-structured interviews. The thematic analysis approach was used to analyze the transcribed documents using MAXQDA software (version 12).The results revealed 2 themes and 6 sub-themes related to the psychological beliefs of individuals with no attention to corona alerts. Themes and sub-themes included Biased cognitive processing (biased beliefs, attention biases, metacognitive beliefs and Depressogenic schemata), low compassion, and empathy for oneself and others (Negative Emotions towards Oneself, low altruism). To ensure a positive attitude towards precautionary measures in society, the thoughts, perceptions, and behaviors of people who ignore coronavirus alerts need to be changed. This is achieved through the use of mass media and virtual networks, by encouraging people to change their negative attitude towards the use of preventive measures, individual and social protection campaigns, and by fostering a sense of responsibility.

Pathways to care among patients with mental illness at two psychiatric facilities in Johannesburg, South Africa

BACKGROUND

A patient's pathway to care is often characterized by a sequence of actions taken to remedy ill-health. Research exploring the help-seeking behavior of individuals with mental health problems in sub-Saharan Africa is relatively limited. This study assessed the perceptions and experiences of mental illness and treatment among patients with mental illness at two psychiatric facilities in Johannesburg, South Africa.

METHODS

309 interviewer administered surveys were conducted between January and July 2022. We used a logistic regression model to examine factors associated with receiving treatment for mental illnesses from traditional healers. Semi-structured interviews were conducted with 18 participants during the same period. Interviews were transcribed and translated into English. Data were managed using NVivo 11 software and thematically analyzed.

FINDINGS

Results showed that 144 (47%) patients sought mental health care from traditional healers. Higher anxiety symptoms, number of people in the household, believing that traditional medicine can cure mental illnesses, and township living were associated with seeking mental healthcare from traditional healers. Qualitative analysis indicated that participants often believed that mental illness was due to bewitchment and consulted with multiple traditional healers, thus spending large amounts of money for treatment and ultimately delaying access to biomedical care.

CONCLUSION

Collaborative approaches between traditional healers and biomedical professionals show promise in terms of allowing for improved identification and treatment of individuals with mental disorders.

Validation of the combined Patient Health Questionnaire Anxiety and Depression Scale among people with HIV in Vietnam

BACKGROUND

Our study aims to examine the factor structure, validity, and reliability of the combined scale Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) among people with HIV (PWH) in Vietnam.

METHODS

Baseline data from an alcohol-reduction intervention trial among ART clients in Thai Nguyen, Vietnam were used for this analysis (n = 1547). A score ≥10 on the PHQ-9, GAD-7 and PHQ-ADS scale was considered having clinically meaningful depression, anxiety and distress symptoms. Factor structure of the combined PHQ-ADS scale was validated using confirmatory factor analysis, and three models were tested: a one-factor, a two-factor, and a bi-factor model. Reliability and construct validity were examined.

RESULTS

The prevalence of clinically meaningful depression and anxiety symptoms was 7% and 2%, respectively, while 19% had distress symptoms. A bi-factor model had the best fit to the data (RMSEA = 0.048; CFI = 0.99; TLI = 0.98). The Omega index of the bi-factor model was 0.97. The scale showed good construct validity through negative associations between depression, anxiety, distress symptoms and quality of life.

CONCLUSIONS

Our study supports the use of a combined scale to measure general distress for PWH, which has good validity, reliability and is unidimensional enough to justify the use of a composite depression and anxiety score.

Prevalence and trends of advanced HIV disease among antiretroviral therapy-naïve and antiretroviral therapy-experienced patients in South Africa between 2010-2021: a systematic review and meta-analysis

BACKGROUND

Despite the significant progress made in South Africa in getting millions of individuals living with HIV into care, many patients still present or re-enter care with Advanced HIV Disease (AHD). We aimed to estimate the prevalence of AHD among ART-naive and ART-experienced patients in South Africa using studies published between January 2010 and May 2022.

METHODS

We searched for relevant data on PubMed, CINAHL, Scopus and other sources, with a geographical filters limited to South Africa, up to May 31, 2022. Two reviewers conducted all screening, eligibility assessment, data extraction, and critical appraisal. We synthesized the data using the inverse-variance heterogeneity model and Freeman-Tukey transformation. We assessed heterogeneity using the I2 statistic and publication bias using the Egger and Begg's test.

RESULTS

We identified 2,496 records, of which 53 met the eligibility criteria, involving 11,545,460 individuals. The pooled prevalence of AHD among ART-naive and ART-experienced patients was 43.45% (95% CI 40.1-46.8%, n = 53 studies) and 58.6% (95% CI 55.7 to 61.5%, n = 2) respectively. The time trend analysis showed a decline of 2% in the prevalence of AHD among ART-naive patients per year. However, given the high heterogeneity between studies, the pooled prevalence should be interpreted with caution.

CONCLUSION

Despite HIV's evolution to a chronic disease, our findings show that the burden of AHD remains high among both ART-naive and ART-experienced patients in South Africa. This emphasizes the importance of regular measurement of CD4 cell count as an essential component of HIV care. In addition, providing innovative adherence support and interventions to retain ART patients in effective care is a crucial priority for those on ART.

Adverse childhood experiences, traumatic events, and mental health among adults at two outpatient psychiatric facilities in Johannesburg, South Africa: a cross-sectional analysis

BACKGROUND

Adverse childhood experiences and adult trauma, including sexual abuse, physical abuse, neglect, and interpersonal violence, are highly prevalent in low-resource settings and associated with adverse psychological outcomes. However, there is limited focus on the impact of ACEs and trauma on mental health in sub-Saharan Africa. Therefore, this study examines the impact of traumatic events and ACEs on depression, anxiety, and stress scores among outpatients receiving psychiatric care at two public mental health treatment facilities in Johannesburg, South Africa.

METHODS

A sample of 309 participants were recruited between January and June 2022 at Helen Joseph Hospital and Alexandra 18th Avenue Clinic. Participants completed screening measures for mental health outcomes, including the 9-item Patient Health Questionnaire (PHQ-9), the 7-item General Anxiety Disorder scale (GAD-7) and the 10-item Perceived Stress Scale. We fitted modified Poisson and linear regression models to estimate the impact of ACEs and adult experiences of trauma on depression, anxiety, and stress scale scores.

RESULTS

47.57% (n = 147) of participants screened positive for anxiety, 44.66% (n = 138) for depression, and 17% (n = 54) for severe stress. More females screened positive for anxiety (65.31%), depression (65.94%), and stress (77.78%). Each ACE was associated with a 12% increased risk of depression, a 10% increased risk of anxiety, and a 17% increased risk of stress. In separately estimated models, each additional traumatic event during adulthood was associated with a 16% increased risk for depression, an 8% increased risk of anxiety, and a 26% increased risk of stress. Across all models, being male and self-reported physical health were consistently associated with a reduced risk for depression, anxiety, and stress.

CONCLUSIONS

ACEs and experiences of traumatic events as adults were associated with significantly increased risks of anxiety, depression, and severe stress. Given high exposure to ACEs and trauma and the associated impact on the mental health of individuals, families, and communities, there is a need to strengthen and scale innovative combination interventions that address multiple stressors impacting people in low-resource settings.

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.

Factors associated with psychological distress during the COVID-19 pandemic: Data from two early waves in Russia

There is limited information about how the mental health of people has changed over time during the COVID-19 pandemic in low- and middle-income countries. In a cross-sectional study, we identified factors associated with psychological distress at two periods immediately after two peaks of the COVID-19 pandemic in Russia. Data were collected via online surveys. In May-June 2020, we surveyed 373 respondents across Russia. In January-February 2021, we surveyed 743 people, using the same approach for survey distribution. With Kessler-10 as a measure of psychological distress, we used regression analysis to determine factors associated with higher psychological distress among Russians. Levels of psychological distress were high in both time periods and did not significantly change between the surveys. Having had COVID-19, losing one's job, experiencing problems accessing healthcare, and changing drinking behaviour during the pandemic were associated with higher psychological distress. Apart from getting sick or worrying about the virus, psychological distress is affected by restrictions and the consequences of the pandemic situation. As the COVID-19 pandemic continues, actions are needed to address the mental well-being of the population in Russia.

Functioning Problems Associated with Health Conditions with Greatest Disease Burden in South Africa: A Scoping Review

A notable rise in health-related disability for which evidence-based rehabilitation is beneficial is evident in low-to-middle income countries. This scoping review aimed to systematically identify and map the most common functioning problems associated with health conditions that contribute most to disability in South Africa using the International Classification of Functioning, Disability and Health (ICF) framework. Peer-reviewed evidence published from January 2006 to December 2021 was systematically searched from five databases. Some 268 studies reporting on functioning problems (impairments, activity limitations, and participation restrictions) in South African adults (>18 years) related to 10 health conditions were included. A total of 130 different functioning problems were mapped to the ICF. The most prevalent problems (top 20) were related to mobility, pain, and mental health but spanned across several ICF domains and were mostly in patients at primary care. The high prevalence and wide range of functioning problems may be particularly burdensome on an already strained primary health care (PHC) system. This points towards targeted planning of innovative strategies towards strengthening rehabilitation service delivery at primary care to address these complexities where there is an inadequate rehabilitation workforce.

Contemporary prevalence and predictors of anxiety among patients living with HIV/AIDS in Ghana

Objectives

To identify the prevalence and associated factors of anxiety in people living with HIV/AIDS in a tertiary centre in Ghana.

Design

The study employed a cross-sectional design.

Setting

The study was conducted in the outpatient HIV clinic of a tertiary hospital.

Participants

Participants were adult PLWHA receiving OPD care, including those established on combined antiretroviral therapy (cART) and newer patients who were not on cART. Four hundred ninety-five participants aged ≥30 years were consecutively enrolled on the study.

Interventions

Demographic and clinical data were collected using standard questionnaires and patient files. Anxiety was assessed using the Hospital Anxiety and Depression Scale (HADS). Multivariate logistic regression analysis was done to identify associated factors.

Main outcome measure

Proportion of PLWHA who had HADS score of ≥8.

Results

Overall prevalence of anxiety was 61.0% (95%CI: 56.6 - 65.3), with no significant difference between recently diagnosed (≤ 6 months, 64.3%) and those with established diagnoses (>6 months, 59.1%). Urban residence (aOR: 1.67, 95%CI: 1.12 - 2.51), alcohol use (aOR: 1.64, 95%CI: 1.13 - 2.38) and depression (aOR: 13.62, 95%CI: 7.91 - 23.45) were independently associated with anxiety.

Conclusion

In this sample, 6 in 10 Ghanaian PLWHA had evidence of anxiety. Liaison with the national mental health service for more comprehensive and integrated care and further research into the mental health of PLWHA is recommended to reduce this high burden of anxiety.

Funding

This study was funded by a grant from the National Institutes of Health Fogarty International Center (R21 TW010479).

Risk factors for late linkage to care and delayed antiretroviral therapy initiation amongst HIV infected adults in sub-Saharan Africa: a systematic review and meta-analyses

BACKGROUND

Late treatment initiation threatens the clinical and public health benefits of antiretroviral therapy (ART). Quantitative synthesises of the existing evidence related to this is lacking in sub-Saharan Africa (SSA), which would help ascertain the best evidence-based interventions. This review aimed to systematically synthesise the available literature on factors affecting linkage to care and ART initiation amongst HIV-infected adults in SSA.

METHODS

Systematic searches were undertaken on four databases to identify observational studies investigating factors affecting both HIV care outcomes amongst adults (age ≥19 years) in SSA, and were published between January 1, 2015 and June 1, 2021. RevMan-5 software was used to conduct meta-analyses and Mantel-Haenszel statistics to pool outcomes with 95% confidence interval and <0.05 level of significance.

RESULTS

Forty-six studies were included in the systematic review, of which 18 fulfilled requirements for meta-analysis. In both narrative review and meta-analyses, factors related to health care delivery, individual perception and sociodemographic circumstances were associated with late linkage to care and delays in ART initiation.

CONCLUSION

This review identified a range of risk factors for late linkage to care and delayed ART initiation amongst HIV-infected adults in SSA. We recommend implementation of patient-centred intervention approaches to alleviate these barriers.

Trends & predictors of non-AIDS comorbidities among people living with HIV and receiving antiretroviral therapy in Lebanon

Combined antiretroviral therapy (cART) increased the life expectancy of people living with Human Immunodeficiency Virus (HIV) (PLHIV) and remarkably reduced the morbidity and mortality associated with HIV infection. Consequently, PLHIV are experiencing non-acquired immunodeficiency syndrome (AIDS) associated comorbid conditions including diabetes, hyperlipidemia, hypertension, and cardiovascular disease. The aim of this study is to determine the frequency of non-AIDS associated comorbid conditions among a cohort of PLHIV on cART in Lebanon.Data were collected between November 2018 and December 2019 from 105 voluntary participants. A standardized questionnaire was used to collect demographic and behavioral data including lifestyle, smoking, physical activity, substance use and abuse in addition to co-infections and family history of non-communicable diseases. Moreover, data on occurrence and treatment of cardiovascular disease, hypertension, diabetes, lipid and metabolic disorders as well as mental health were collected. Blood samples were used to assess the levels of fasting blood sugar (FBS), glycosylated hemoglobin (HbA1C), triglycerides (TG), low-density lipoprotein (LDL), high-density lipoprotein, total cholesterol, and serum creatinine.Hypertension (29.5%) and hyperlipidemia (29.5%) followed by diabetes (23.7%) and cardiovascular disease (9.7%) were mainly reported among study participants. Higher rate of comorbid conditions was observed among participants >40 years of age than those ≤40 years with both hypertension and hyperlipidemia most commonly reported. Older age (odds ratio [OR] 7.6; 95% CI: 1.83-31.98; P = .005) is associated with higher odds of having hyperlipidemia. Moreover, participants on cART for ≥10 years are 5 times more likely to have hyperlipidemia (OR 5; 95% CI: 1.08-22.73; P = .039). Our results also showed that study participants did not experience anxiety, depression or somatic symptoms and that there was no association between these mental disorders and older age or comorbidities.Our results provide important information on HIV trends and associated comorbidities in Lebanon and can be used to improve the management of non-communicable diseases among PLHIV.

The worldwide prevalence of anxiety in acquired immune deficiency syndrome patients: A systematic review and meta-analysis

Background: Anxiety affects social, economic, and physical aspects of daily life in patients with AIDS. Therefore, it is necessary to take preventive measures and design plans to maintain their general health. The present study was the first comprehensive systematic literature review research that examined the worldwide prevalence rate of anxiety in patients with AIDS.

Methods: We searched for papers published in the English language in the major databases including Embase, PubMed, Web of Science, Scopus, Cochrane, and Google Scholar from 2000 to October 2018. There were 40 studies which found to be eligible. These studies were independently evaluated and the collected data were entered in a data extraction form, which was then analyzed by two authors and a third author if necessary. Der Simonian-Laird model was used to estimate the prevalence rate on a Forest plot at the interval confidence of 95%.

Results: The total sample size was 24111, and the total number of people with anxiety was 5546. The results based on the random-effects model showed that the rate of anxiety prevalence in the patients was 25% (CI: 95%, 21% -30%) with heterogeneity of 97.9% and a significance level of p<0.001. The South America continent with a prevalence of 38% (95% CI, 34%-42%) had the highest anxiety prevalence rates and Africa with 19% (95% CI, 12% -29%) had the lowest anxiety prevalence rates.

Conclusion: Based on findings, the prevalence of anxiety in developed countries was partially higher than in underdeveloped countries and the obtained mean in the present study. It can be a significant point for policymakers. Therefore, WHO and the world community should have special plans for these countries.

Global Systematic Review of Common Mental Health Disorders in Adults Living with HIV

PURPOSE OF THE REVIEW

By reviewing the most recent common mental health disorders (CMHD) studies in people living with HIV (PLWH) (2018-2020), this review discusses the prevalence of CMHD, factors associated with CMHD in PLWH, mental health in PLWH from vulnerable groups, the impact of CMHD on HIV disease progression and adherence to antiretroviral therapy and the efficacy of different treatment approaches.

RECENT FINDINGS

After screening for eligibility 142 studies were included in the final systematic review. Only 27% of studies were conducted in Sub-Saharan Africa, which carries the highest burn of HIV disease globally. Despite the well-established increased risk of CMHD in PLWH, the current prevalence remains high, with studies reporting 28%-62% of PLWH having mental health symptoms.

CONCLUSION

Despite the significant challenges that CMHDs present to successful HIV treatment, there are many mental health treatments and interventions which can improve outcomes in PLWH and opportunities to task-shift and integrate mental health care with HIV care.

Gender, Mental Health, and Entry Into Care with Advanced HIV Among People Living with HIV in Cameroon Under a National 'Treat All' Policy

Delays in diagnosis and linkage to HIV care persist among people living with HIV (PLWH), even after expanded access to ART worldwide. Mental health may influence timely linkage to HIV care. Greater understanding of the relationship among gender, mental health, and delayed linkage to HIV care can inform strategies to improve the health of PLWH. We interviewed 426 PLWH initiating HIV care in Cameroon between June 2019 and March 2020 to estimate the prevalence of depression, anxiety, and post-traumatic stress disorder (PTSD) and the association between mental health and entry into care with advanced HIV. Separate multivariable log binomial regression models were used to estimate the association between mental health exposure and entry into HIV care with advanced HIV. Stratified analyses were used to assess effect modification by gender. Approximately 20, 15, and 12% of participants reported symptoms of depression, PTSD, and anxiety, respectively. The prevalence of mental health symptoms did not vary significantly by gender. Overall, 53% of participants enrolled in HIV care with advanced HIV: 51% of men and 54% of women. Screening positive for one of the mental health disorders assessed was associated with greater prevalence of enrollment with advanced HIV among men, but not among women. Future research should examine gender-specific pathways between mental health symptoms and entry into care with advanced HIV, particularly for men in Cameroon. The extent to which untreated mental health symptoms drive gender disparities throughout the HIV care continuum should be explored further.

What Shapes Late HIV Diagnosis in Vietnam? A Qualitative Investigation of Multilevel Factors

Late HIV treatment remains a global public health issue despite significant efforts. To better understand what shapes this issue, we interviewed 36 Vietnamese ART-naive patients who came to HIV treatment in 2017. Half of them had intake CD4 counts fewer than 100 cells/mm³, the others had intake CD4 counts of 350 cells/mm³ and above. Late diagnosis was the reason of late treatment in our sample. Most late presenters were not members of the key populations at increased risk of HIV (e.g., people who inject drugs, commercial sex workers, and men who have sex with men). Individual-level factors included low risk appraisal, habit of self-medication, and fear of stigma. Network and structural-level factors included challenges to access quality health care, normalization of HIV testing in key populations and inconsistent provider-initiated HIV testing practices. Structural interventions coupled with existing key population-targeted strategies would improve the issue of late HIV diagnosis.

[Anxiety in times of COVID-19 and other health crises]

BACKGROUND

Epidemics and pandemics and the measures taken to contain their spread are accompanied by numerous stressors, which can lead in particular to severe anxiety.

OBJECTIVE

This article describes the components and determinants of these anxiety symptoms, potential resilience and risk factors and appropriate recommendations for action.

METHODS

The article presents an overview of research results regarding COVID-19 and previous epidemics and pandemics (e.g., HIV, SARS, MERS, Ebola and swine flu). Furthermore, official recommendations for action are presented.

RESULTS

Anxiety symptoms frequently occur in epidemics and pandemics, especially in the early phase and usually decrease in the further course. Although other aspects of different infectious diseases vary, the associated fears are similar and include e.g. the fear of health-related, social and economic consequences. Resilience and risk factors in various epidemics and pandemics are comparable. Self-efficacy expectation, tolerance of uncertainty, normalization, routines, safety and social support usually have a protective effect. In contrast, excessive media consumption, female gender, work in a medical context, suppression, pre-existing diseases, unhealthy behavior and closer exposure to the virus are often accompanied by more severe anxiety.

CONCLUSION

Fears should be observed and addressed in order to reduce pathological processes, especially in vulnerable groups. It is advisable to promote resilience factors and to counteract risk factors with preventive and therapeutic measures. For this purpose, the development and empirical testing of specific interventions as well as further longitudinal studies are needed.

Association Between Depression and HIV Care Engagement Outcomes Among Patients Newly Initiating ART in Lilongwe, Malawi

As in other sub-Saharan countries, the burden of depression is high among people living with HIV in Malawi. However, the association between depression at ART initiation and two critical outcomes-retention in HIV care and viral suppression-is not well understood. Prior to the launch of an integrated depression treatment program, adult patients were screened for depression at ART initiation at two clinics in Lilongwe, Malawi. We compared retention in HIV care and viral suppression at 6 months between patients with and without depression at ART initiation using tabular comparison and regression models. The prevalence of depression among this population of adults newly initiating ART was 27%. Those with depression had similar HIV care outcomes at 6 months to those without depression. Retention metrics were generally poor for those with and without depression. However, among those completing viral load testing, nearly all achieved viral suppression. Depression at ART initiation was not associated with either retention or viral suppression. Further investigation of the relationship between depression and HIV is needed to understand the ways depression impacts the different aspects of HIV care engagement.

The need for an integrated pharmacological response to the treatment of HIV/AIDS and depression

Introduction: The coexistence of depression and HIV infection affects more than 9 million people worldwide. A literature review revealed a large gap regarding the pharmacotherapy of depression among patients dually diagnosed with HIV and depression.Areas covered:In this review, the authors covered the various dimensions of deploying integrated pharmacological treatment of HIV/AIDS and depression. This topic was addressed in two ways; first, the direct results of integrated pharmacotherapy in syndemic patients; second, the indirect effects of the integrated model on other outcomes of HIV care.Expert opinion: An integrated pharmacological response to the treatment of HIV and depression can bring substantial benefits to HIV outcomes and reduce the burden of both diseases. The direct advantages regarding pharmacological response to the treatment of depression along with HIV care are improving adherence to antiretroviral therapy, optimizing pharmacotherapy, minimizing drug interaction, and prevention of additive adverse drug reactions. Furthermore, in some cases, medication can target both depression and other neuropsychiatric or somatic comorbidities among people living with HIV/AIDS. The integrated pharmacotherapy also has some potential indirect advantages on HIV care outcomes like minimizing loss of care, reducing ongoing HIV transmission, and improving the outcomes of both diseases.

"As a Young Pregnant Girl… The Challenges You Face": Exploring the Intersection Between Mental Health and Sexual and Reproductive Health Amongst Adolescent Girls and Young Women in South Africa

In South Africa, adolescent girls and young women (AGYW) are at risk of poor mental health, HIV infection and early pregnancy. Poor mental health in AGYW is associated with increased sexual risk behaviours, and impeded HIV testing and care. Using in-depth interviews and focus group discussions, we explored subjective experiences of mental health and sexual and reproductive health (SRH) amongst 237 AGYW aged 15-24 years in five South African districts. Respondents shared narratives of stress, emotional isolation, feelings of depression, and suicidal ideation, interconnected with HIV, pregnancy and violence in relationships. Findings show that AGYW in South Africa face a range of mental health stressors and lack sufficient support, which intersect with SRH challenges to heighten their vulnerability. Framed within the syndemic theory, our findings suggest that South African AGYW's vulnerability towards early pregnancy, HIV infection and poor mental health are bidirectional and interconnected. Considering the overlaps and interactions between mental health and SRH amongst AGYW, it is critical that mental health components are integrated into SRH interventions.

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

BACKGROUND

Since mental health may influence HIV care among people living with HIV (PLHIV), we sought to evaluate the impact of anxiety and depression on ART initiation and HIV-related outcomes.

METHODS

We conducted a prospective cohort study of PLHIV in the Umlazi Township of KwaZulu-Natal, South Africa. We measured depression using the Patient Health Questionnaire (PHQ-9) and anxiety using the Generalized Anxiety Disorder (GAD-7) scale, both of which have been validated in sub-Saharan Africa, among all patients prior to receiving a positive HIV test. We then followed those who tested HIV+ for 12 months to determine their time to ART initiation, missing clinic visits or refills, retention in care, hospitalization, and death. We used logistic regression models, adjusted for socio-demographic characteristics such as age and sex, to examine the effects of baseline measures of depression and anxiety on ART initiation and HIV treatment outcomes.

FINDINGS

Among 2,319 adult PLHIV, mean age was 33 years (SD=9.3 years), 57% were female, and baseline median CD4 count was 317 cells/mm³ (IQR=175-491 cells/mm³). In univariate analyses, depression was associated with slower rates of ART initiation. In adjusted models, PLHIV with depression had lower odds of initiating ART within 90 days of HIV testing (aOR=0.60, 95% CI=0.46, 0.79, p<0.01), and lower odds of being retained in care (aOR=0.77, 95% CI=0.60, 0.99, p = 0.04). By the end of the 12-month study period, odds of ART initiation among PLHIV with depression were higher than the first 90 days but still significantly lower compared to those without depression (aOR=0.72, 95% CI=0.52, 0.99, p = 0.04). Among PLHIV who initiated ART, depression was associated with a lower odds of missing clinic visits (aOR=0.54, 95% CI= 0.40, 0.73, p<0.01). Anxiety was strongly correlated with depression (r = 0.77, p<0.01) and had similar effects on HIV-related outcomes.

INTERPRETATIONS

The presence of depression is a significant barrier to ART initiation and retention in care among adult PLHIV in South Africa. Mental health screenings around the time of HIV testing may help improve linkage and HIV-related outcomes.

FUNDING

This work was supported by the Infectious Disease Society of America Education & Research Foundation and National Foundation for Infectious Diseases (PKD); Massachusetts General Hospital Executive Committee on Research (PKD); the Harvard University Center for AIDS Research [AI060354] (PKD); and the National Institute of Allergy and Infectious Diseases [AI108293, AI143351] (PKD). The content is solely the responsibility of the authors and does not represent the official views of the National Institutes of Health or other funding agencies.

Depression symptoms, HIV testing, linkage to ART, and viral suppression among women in a high HIV burden district in KwaZulu-Natal, South Africa: A cross-sectional household study

Achieving the UNAIDS 90-90-90 targets by 2020 is contingent on identifying and addressing mental health challenges that may affect HIV testing and treatment-related behaviors. This study is based on survey data from KwaZulu-Natal, South Africa (2014–2015). HIV positive women who reported higher depression scores had a lower odds of having tested previously for HIV (15–25 years: AOR = 0.90, 95% CI [0.83, 0.98]; 26–49 years: AOR = 0.90, 95% CI [0.84, 0.96]). Because HIV testing behavior represents a gateway to treatment, the findings suggest mental health may be one challenge to attaining the UNAIDS 90-90-90 targets.

"Vital": HIV counselling and testing staff's views of addressing mental health with HIV in Uganda

BACKGROUND

Mental health is linked to HIV outcomes, including linkage into care and adherence to medication. Integrated care for mental and physical health is recommended. HIV testing and counselling sessions represent an opportunity to implement interventions to address mental health, however it is first necessary to understand the roles, current practice, knowledge and attitudes of the testing and counselling staff.

METHODS

This qualitative study used semi-structured interviews with HIV testing and counselling staff at four centres of a HIV healthcare provider charity in Uganda. Interviews focused on their current practice, perceptions of mental health and their role in supporting this, challenges of this work, training and support needs, and views of potential greater emphasis on mental health work in their role. Data were audio-recorded, transcribed verbatim, and analysed thematically.

RESULTS

Data from twenty-one testing and counselling staff revealed five themes. Clients presented to counselling staff with needs spanning bio-psycho-social domains, where psychological health was intertwined with HIV management, medication adherence, and seen as "inseparable" from HIV itself. Mental health was largely thought about as "madness", identifiable from extreme behaviour. As such, common mental health problems of anxiety and depression were not often seen as part of mental health. Approaches to intervening with mental health were seen as behavioural, with some ideas about changing thinking styles. Participants demonstrated significant practice of common techniques to address mental health. Needs were identified for further training in suicide risk assessment and identification of depression, together with greater clinical supervision. Participants described significant conflict within their roles, particularly balancing time demands and need to achieve testing targets against the need to offer adequate mental health support to clients in need.

CONCLUSIONS

HIV testing and counselling staff described a diverse role that already includes addressing mental health. Mental health is "vital" to their work, however the time needed to address it is at odds with current testing targets. They require more training and resources to effectively address mental health, which is vital to optimising HIV outcomes. Interventions to integrate mental health support into HIV testing and counselling sessions need to be further researched and optimised.

Prevalence of and factors associated with advanced HIV disease among newly diagnosed people living with HIV in Guangdong Province, China

INTRODUCTION

A high proportion of people living with HIV (PLHIV) present for care with advanced HIV disease (AHD), which is detrimental to "90-90-90" targets to end AIDS by 2030. This study aimed to explore the prevalence of and factors related to AHD among newly diagnosed PLHIV in Guangdong Province, China.

METHODS

Newly diagnosed PLHIV were recruited from six cities in Guangdong Province from May 2018 to June 2019. AHD was defined as an initial CD4 count <200 cells/µL or an AIDS-defining event within one month of HIV diagnosis. Data from a questionnaire and the national HIV surveillance system were used to explore the potential factors related AHD.

RESULTS

A total of 400 of 997 newly diagnosed PLHIV were defined as having AHD with a proportion of 40.1%. After adjusting for statistically significant variables in univariate analysis, multivariable logistic regressions showed that individuals aged 30 to 39 years (adjusted odds ratio (aOR) = 1.77, 95% confidence interval (CI): 1.13 to 2.79) and ≥50 years (aOR = 1.98, 95% CI: 1.15 to 3.43) were at a higher risk of AHD than those aged 18 to 29 years. Participants diagnosed by voluntary counselling and testing (VCT) clinics were less likely to have AHD (aOR = 0.67, 95% CI: 0.48 to 0.94) than those diagnosed at medical facilities. Participants who had ever considered HIV testing (aOR = 0.66, 95% CI: 0.45 to 0.98) and who had high social support (aOR = 0.73, 95% CI: 0.55 to 0.97) were at a lower risk of AHD, whereas participants who had HIV-related symptoms within one year before diagnosis were at a higher risk of AHD (aOR = 2.09, 95% CI: 1.58 to 2.77). The most frequent reason for active HIV testing was "feeling sick" (42.4%, 255/601), and the main reason for never considering HIV testing was "never thinking of getting HIV" (74.0%, 542/732).

CONCLUSIONS

Low-risk perception and a lack of awareness of HIV-related symptoms resulted in a high proportion of AHD in Guangdong Province, especially among the elderly, those diagnosed at medical facilities and those with low social support. Strengthening AIDS education and training programmes to scale up HIV testing through provider-initiated testing and counselling in medical facilities and VCT could facilitate early HIV diagnosis.

The reliability, validity and factorial structure of the Swahili version of the 7-item generalized anxiety disorder scale (GAD-7) among adults living with HIV from Kilifi, Kenya

BACKGROUND

Generalized Anxiety Disorder (GAD) is under-investigated in people living with HIV/AIDS from sub-Saharan Africa. In part, this is due to paucity of culturally appropriate measures for GAD which are psychometrically robust. This study aimed to evaluate the reliability, factorial structure, and validity of Swahili version of the 7-item GAD questionnaire (GAD-7) among adults living with HIV.

STUDY DESIGN

Descriptive cross-sectional study.

METHODS

450 adults receiving comprehensive care from an HIV specialized clinic in Kilifi County, coastal Kenya, were consecutively recruited. Swahili versions of GAD-7, Patient Health Questionnaire (PHQ-9) and a 12-item HIV stigma scale were administered alongside measures of psychosocial and health-related characteristics. Internal consistency, test-retest reliability, factorial structure, convergent validity, and discriminant validity of Swahili GAD-7 were examined using Cronbach's alpha (α), intra-class correlation coefficient (ICC), Confirmatory Factor Analysis (CFA), Pearson's correlation, and analysis of covariance (ANCOVA), respectively.

RESULTS

Internal consistency of Swahili GAD-7 was good, α = 0.82 (95% CI 0.78, 0.85). Its test-retest reliability (2 weeks apart) was acceptable, ICC = 0.70 (95% CI 0.55, 0.81). A confirmatory analysis of a one-factor solution indicated an excellent fit to the hypothesized structure (RMSEA = 0.00 [95% confidence interval 0.00, 0.05], CFI = 1.00, TLI = 1.00). Multi-group CFA substantiated factorial invariance for sex and age for the one-factor structure of Swahili GAD-7. Scores of GAD-7, Swahili version, significantly correlated with those of PHQ-9 (r = 0.73; p < 0.001) and the HIV stigma scale (r = 0.36; p < 0.001) suggesting good convergent validity. Statistically significant differences were observed between participants on first-line antiretroviral therapy compared to those on second-line treatment (F [1, 441] = 5.55, p = 0.02) indicative of good discriminant validity of Swahili GAD-7.

CONCLUSION

GAD-7 Swahili version retained its original unidimensional latent structure with good psychometric properties among adults living with HIV from Kilifi, Kenya. It can be used to identify symptoms of GAD in similar research settings. However, to confidently identify those in need of mental health treatment or referral services in HIV primary care clinics, more research on the validity of Swahili GAD-7 is needed especially its discriminant validity and diagnostic accuracy at different cut-off scores.

Electronic dose monitoring identifies a high-risk subpopulation in the treatment of drug-resistant tuberculosis and HIV

BACKGROUND

In generalized drug-resistant tuberculosis (DR-TB) HIV epidemics, identifying subpopulations at high risk for treatment failure and loss to care is critically important to improve treatment outcomes and prevent amplification of drug resistance. We hypothesized that an electronic dose-monitoring (EDM) device could empirically identify adherence-challenged patients and that a mixed-methods approach would characterize treatment challenges.

METHODS

A prospective study of DR-TB HIV patients on antiretroviral therapy (ART) initiating bedaquiline-containing regimens in KwaZulu-Natal, South Africa. Separate EDM devices measured adherence for bedaquiline and ART. Patients with low adherence (<85%) to both bedaquiline and ART were identified as high-risk for poor outcomes. Baseline survey, study visit notes and focus group discussions characterized treatment challenges.

RESULTS

From December 2016-February 2018, 32 of 198 (16%) enrolled DR-TB HIV patients were identified as dual adherence-challenged. In a multivariate model including baseline characteristics, only receiving a disability grant was significantly associated with dual non-adherence at 6-months. Mixed-methods identified treatment barriers including, alcohol abuse, family conflicts, and mental health issues. Compared to adherent patients, dual-adherence challenged patients struggled to prioritize treatment and lacked support, and dual adherence-challenged patients experienced higher rates of detectable HIV viral load and mortality compared to more adherent patients.

CONCLUSION

EDM empirically identified a subpopulation of DR-TB HIV patients with dual adherence challenges early in treatment. Mixed-methods revealed intense psychosocial, behavioral, and structural barriers to care in this subpopulation. Our data supports developing differential, patient-centered, adherence support interventions focused on psychosocial and structural challenges for subpopulations of at-risk DR-TB HIV patients.

Linkage to Care Following an HIV Diagnosis in Three Public Sector Clinics in eThekwini (Durban), South Africa: Findings from a Prospective Cohort Study

Linkage to care following an HIV diagnosis remains an important HIV care continuum milestone, even in the era of universal ART eligibility. In an 8-month prospective cohort study among 459 (309 women, 150 men) newly-diagnosed HIV-positive individuals in three public-sector clinics in Durban metropolitan region, South Africa, from 2010 to 2013, median time to return to clinic for CD4+ results (linkage) was 10.71 weeks (95% CI 8.52-12.91), with 54.1% 3-month cumulative incidence of linkage. At study completion (9.23 months median follow-up), 26.2% had not linked. Holding more positive outcome-beliefs about enrolling in care was associated with more rapid linkage [adjusted hazard ratio (AHR)each additional belief 1.31; 95% CI 1.05-1.64] and lower odds of never linking [adjusted odds ratio (AOR) 0.50; 95% CI 0.33-0.75]. Holding positive ARV beliefs was strongly protective against never linking to care. Age over 30 years (AHR 1.59; 95% CI 1.29-1.97) and disclosing one's HIV-positive status within 30 days of diagnosis (AHR 1.52; 95% CI 1.10-2.10) were associated with higher linkage rates and lower odds of never linking. Gender was not associated with linkage and did not alter the effect of other predictors. Although expanded access to ART has reduced some linkage barriers, these findings demonstrate that people's beliefs and social relations also matter. In addition to structural interventions, consistent ART education and disclosure support, and targeting younger individuals for linkage are high priorities.

Anxiety and depression among women living with HIV in Kazakhstan

An increase in new HIV infections among women in Kazakhstan has motivated efforts to improve access to comprehensive health services. This study estimates anxiety and depression frequency among women seeking HIV services. A cross-sectional survey was administered to women seen at the Almaty AIDS Center. Bivariable analyses (e.g., Chi-square, means with 95% confidence intervals) were performed to assess the relationship between anxiety (score of 10 or more on the Generalized Anxiety Disorder-7 Scale (GAD-7)), major depression (Patient Health Questionnaire 8 (PHQ-8)), and comorbid anxiety and major depression with sociodemographic characteristics, health functioning, and medication history. Of the 410 participants, 62 (15.1%) had a GAD-7 ≥ 10; 52 (12.7%) met major depression criteria; 35 (8.5%) met both criteria, and 79 (19.3%) met GAD-7, major depression, or both criteria. Women reporting depression or anxiety were more likely to lack food security (p < 0.01), not finish secondary school (p < 0.01), speak Russian at home (p < 0.01), perceive their health to be poor (p < 0.01), and report poorer physical and mental health functioning (p < 0.05). No medications approved for the treatment of anxiety or depression were reported. The considerable number of women reporting major depression and anxiety symptoms suggests a need for improving access to mental health care.

Depressive Symptoms and Sexually Transmitted Disease: Evidence from a Low-Income Neighborhood of New York City

We examined the association between sexually transmitted disease (STD) and depressive symptoms. Our analysis utilized the 2015 cross-sectional Washington Heights Community Survey. Multivariable binary logistic regression analysis was used to examine the primary association between having a history of STD and patient health questionnaire-9 (PHQ-9) score while adjusting for potential confounders. Then in separate models, we adjusted for the interaction of social factors with PHQ-9 score to test for modification effect on the primary association. In this low-income neighborhood, STD history was not significantly associated with PHQ-9 score in the overall logistic regression model for the primary association. However, in interaction models, STD and depressive symptoms were associated in sub-groups defined by social factors, namely being Hispanic [odds ratio (OR) 1.08; 95% confidence interval (CI) 1.02-1.15], foreign-born (OR 1.08; 95% CI 1.02-1.15), and having low to moderate social support (OR 1.09; 95% CI 1.02-1.15). Our results demonstrate a need for targeted interventions to be applied to vulnerable subgroups identified.

The Role of Depression Screening and Treatment in Achieving the UNAIDS 90-90-90 Goals in Sub-Saharan Africa

Despite widespread HIV screening and treatment programs across sub-Saharan Africa, many countries are not on course to meet the Joint United Nations Program on HIV/AIDS 90–90–90 targets. As mental health disorders such as depression are prevalent among people living with HIV, investment in understanding and addressing comorbid depression is increasing. This manuscript aims to assess depression and HIV management in sub-Saharan Africa using a 90–90–90 lens through a discussion of: depression and the HIV care continuum; the state of depression screening and treatment; and innovations such as task-shifting strategies for depression management. Due to the lack of mental health infrastructure and human resources, task-shifting approaches that integrate mental health management into existing primary and community health programs are increasingly being piloted and adopted across the region. Greater integration of such mental health care task-shifting into HIV programs will be critical to realizing the 90–90–90 goals and ending the HIV epidemic.

Longitudinal trajectories of emotional problems and unmet mental health needs among people newly diagnosed with HIV in China

INTRODUCTION

Concern over mental health morbidity affecting people living with HIV is increasing worldwide. The objective of this study was to describe the longitudinal trajectories of depression and anxiety, and mental health service utilization among people newly diagnosed with HIV.

METHODS

This was an observational cohort study that enrolled people newly diagnosed with HIV consecutively and followed them for one year in Changsha, China. Socio-demographic, clinical and psychological data were collected at the baseline and at one-year follow-up. Participants were recruited between March 1, 2013 and September 30, 2014. The final follow-up was in September 30, 2015.

RESULTS

Among 557 people newly diagnosed with HIV enrolled at the baseline, 410 (73.6%) completed the one-year follow-up survey (median (interquartile range) age at follow-up: 29 (25, 39) years; 376 men (91.7%)), and were included in the analysis. 39.3% and 30.2% of the 410 participants were screened with significant symptoms of depression and anxiety at baseline respectively. An overall drop in the prevalence of each condition was found at follow-up, however, 10.5% and 6.1% of participants were found to have persistent depression and anxiety. The results of mixed-effect models showed that bisexuality, homosexual transmission, other clinical symptoms (for example, not on antiretroviral therapy (ART)), non-disclosure, higher levels of HIV/AIDS-related stress, and lack of social support were associated with significant symptoms of depression and anxiety. One year after diagnosis, 8.3% had visited healthcare providers for emotional or psychological problems.

CONCLUSIONS

Despite the obvious need people newly diagnosed with HIV in China rarely seek professional help. Integrating depression and anxiety screening and referral into HIV care settings is warranted.

Symptom Clusters in People Living With HIV: A Systematic Review

CONTEXT

An increasing number of studies regarding symptom management have begun to shift their focus from managing a single symptom to multiple symptom clusters. However, there is a lack of consistency of compositions among different studies and even in two different analyses reported in a single study within the same population.

OBJECTIVES

The aim of this systematic review was to summarize the compositions, measures, and data analysis techniques of symptom clusters in people living with HIV (PLWH).

METHODS

We conducted a comprehensive search to identify published studies about symptom clusters among PLWH. Databases including PubMed/MEDLINE, MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), Web of Science, and ProQuest Dissertations and Thesis were searched for studies published between January 2000 and December 2018.

RESULTS

Thirteen articles were eligible for inclusion. Five most commonly reported symptom clusters were found: 1) sad/depressed/loss of interest and nervous/anxious/worrying; 2) difficulty sleeping, problems with having sex, and fatigue/loss of energy; 3) fever/chills/sweat, nausea/vomiting, and loss of appetite; 4) numbness, muscle aches, and joint pain; and 5) dizziness and headache.

CONCLUSION

This systematic review summarized the compositions, measures, and analytical techniques of symptom clusters for PLWH. Although this review found unstable results on the compositions of symptom clusters and it was difficult to reach a definitive conclusion, the results still implicate the necessity of developing a threshold to decide what symptoms should be included in the clusters and the use of multiple data analysis techniques to obtain stable results.

The effectiveness of depression management for improving HIV care outcomes in Malawi: protocol for a quasi-experimental study

BACKGROUND

Depression, prevalent among people living with HIV (PLWH) in Malawi, is associated with negative HIV patient outcomes and likely affects HIV medical management. Despite the high prevalence of depression, its management has not been integrated into HIV care in Malawi or most low-income countries.

METHODS

This study employs a pre-post design in two HIV clinics in Lilongwe, Malawi, to evaluate the effect of integrating depression management into routine HIV care on both mental health and HIV outcomes. Using a multiple baseline design, this study is examining mental health and HIV outcome data of adult (≥18 years) patients newly initiating ART who also have depression, comparing those entering care before and after the integration of depression screening and treatment into HIV care. The study is also collecting cost information to estimate the cost-effectiveness of the program in improving rates of depression remission and HIV treatment engagement and success.

DISCUSSION

We anticipate that the study will generate evidence on the effect of depression management on HIV outcomes and the feasibility of integrating depression management into existing HIV care clinics. The results of the study will inform practice and policy decisions on integration of depression management in HIV care clinics in Malawi and related settings, and will help design a next-step strategy to scale-up integration to a larger scale.

TRIAL REGISTRATION

ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.

Understanding the role of resilience resources, antiretroviral therapy initiation, and HIV-1 RNA suppression among people living with HIV in South Africa: a prospective cohort study

OBJECTIVE

Failure to initiate antiretroviral therapy (ART) and achieve virologic suppression are significant barriers to the United Nations 90-90-90 goals. Identifying resilience resources, or modifiable strength-based factors, among people living with HIV is critical for successful HIV treatment and prevention.

DESIGN

Prospective cohort study.

METHODS

From July 2014 to July 2015, 500 adults presenting for voluntary counseling and HIV testing who were diagnosed with HIV and were ART-eligible in South Africa (Soweto and Gugulethu) were enrolled and surveyed. Logistic regression models assessed resilience-related predictors of ART initiation within 6 months of voluntary counseling and HIV testing for HIV, and HIV-1 plasma RNA suppression within 9 months, adjusting for sociodemographic factors.

RESULTS

Within 6 months, 62% initiated ART, and within 9 months, 25% had evidence of an undetectable HIV-1 plasma RNA (<50 copies/ml). Participants who initiated ART relied less on social support from friends [adjusted odds ratio (aOR) 0.94, 95% confidence interval (CI): 0.89-0.99], coped using self-distraction (aOR 1.05, 95% CI: 1.00-1.10) and avoided coping through substance use (aOR 0.79, 95% CI: 0.65-0.97), as compared with participants who did not initiate ART. Those who achieved plasma RNA suppression relied more on social support from a significant other/partner (aOR 1.04, 95% CI: 1.02-1.07), used positive religious coping (aOR 1.03, 95% CI: 1.00-1.07), and were less likely to engage in denial coping (aOR 0.84, 95% CI: 0.77-0.92), compared with those who initiated ART but did not achieve plasma RNA suppression.

CONCLUSION

Interventions optimizing resilience resources and decreasing maladaptive coping strategies (e.g., substance use, denial) may present a feasible approach to maximizing ART-based HIV treatment strategies among South African people living with HIV.

HIV late presentation and advanced HIV disease among patients with newly diagnosed HIV/AIDS in Southwestern China: a large-scale cross-sectional study

OBJECTIVE

This study aimed to investigate the prevalence of HIV late presentation and advanced HIV disease and to identify the factors associated with HIV late presentation and advanced HIV disease among patients with newly diagnosed HIV/AIDS in the Guangxi Zhuang Autonomous Region, in Southwestern China.

METHODS

Patients with newly diagnosed HIV registered in the HIV surveillance system of Guangxi Centers for Disease Control between January 2012 and December 2016 were included in this study.

RESULTS

Of 45,118 newly diagnosed patients, 70.2% had late presentation, and 45.1% had advanced HIV disease. A higher prevalence of late presentation and advanced HIV disease was found in male heterosexuals and female people who use drugs (PWID). Heterosexuals (OR 2.11 [95% CI 1.90-2.34]) and PWID (OR 1.55 [95% CI 1.30-1.84]) had a higher risk of late presentation than men who have sex with men (MSM). Blood testing of the blood receivers (OR 1.75 [95% CI 1.36-2.26]) and diagnosed in hospital (OR 1.74 [95% CI 1.65-1.84]) had an increased risk of late presentation compared to those who diagnosis in voluntary counseling and testing (VCT). Heterosexuals (OR 2.86 [95% CI 2.51-3.27]), PWID (OR 2.23 [95% CI 1.83-2.71]), blood testing of the blood receivers (OR 1.58 [95% CI 1.29-1.94]) and diagnosed in hospital (OR 1.85 [95% CI 1.76-1.94]) were also independent risk factors associated with advanced HIV disease. Older age, lower level of education and being divorced or widowed were also associated with late presentation and advanced HIV disease.

CONCLUSIONS

Late presentation and advanced HIV disease were very common among patients with newly diagnosed HIV in Guangxi, China during 2012-2016. Targeted programs are urgently required to reduce HIV late diagnosis in Guangxi, especially for male heterosexuals, PWID, and patients with characteristics such as older age, lower level of education, divorced or widowed.

Digital depression screening in HIV primary care in South Africa: mood in retroviral + application monitoring [MIR + IAM]

BACKGROUND

Integrating mental health care into HIV services is critical to addressing the high unmet treatment needs for people living with HIV and comorbid major depressive disorder. Introducing routine mental health screening at the primary health care level is a much needed diagonal approach to enhancing HIV care. In low-resource settings with a shortage of mental health care providers, eMental Health may provide a novel opportunity to attenuate this treatment gap and strengthen the health system.

OBJECTIVE

To conduct formative health systems research on the implementation of routine depression screening using a digital tool - Mood in Retroviral Positive Individuals Application Monitoring (MIR  +  IAM) - in an HIV primary care setting in South Africa.

METHODS

A Theory of Change (ToC) approach was utilised through individual and group session interviews to design an intervention that is embedded in the local context. Ten experts and local stakeholders were selected from the UK and South Africa. Data were analysed thematically using Atlas.ti to identify interventions, assumptions, barriers and facilitators of implementation.

FINDINGS

The participants considered digital depression screening in HIV care services relevant for the improvement of mental health in this population. The six main themes identified from the ToC process were: (1) user experience including acceptability by patients, issues of patient privacy and digital literacy, and the need for a patient-centred tool; (2) benefits of the digital tool for data collection and health promotion; (3) availability of treatment after diagnosis; (4) human and physical resource capacity of primary health care; (5) training for lay health care workers; and (6) demonstration of the intervention's usefulness to generate interest from decision-makers.

CONCLUSION

Digital depression screening coupled with routine mental health data collection and analysis in HIV care is an applicable service that could improve the mental and physical health outcomes of this population. Careful consideration of the local health system capacity, including both workers and patients, is required. Future research to refine this intervention should focus on service users, government stakeholders and funders.

Mental health and HIV: research priorities related to the implementation and scale up of 'treat all' in sub-Saharan Africa

World Health Organization (WHO) guidelines call for antiretroviral therapy (ART) for all people living with HIV (PLWH) regardless of CD4 cell count, a policy often referred to as 'treat all'. This article seeks to: (1) provide an overview of mental health research among PLWH in sub-Saharan Africa (SSA) and interventions or strategies to address comorbid mental illness among those living with HIV; and (2) describe key mental health-related recommendations to inform the successful implementation and scale up of 'treat all' policies in SSA. An initial set of mental health-related research recommendations was developed by a working group comprising investigators affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Recommendations were shared with those who attended the All-Africa IeDEA Meeting in Kigali, Rwanda in November 2017 and refined following the meeting. Recommendations reflect a need for epidemiological research to examine the prevalence, incidence, and impact of mental health multimorbidities on HIV treatment outcomes, intervention research to examine the extent to which improving the mental health of people living with HIV enhances HIV treatment outcomes, and implementation science research to evaluate promising models of integrated mental health and HIV care. Key research recommendations can advance understanding and treatment of mental illness among those living with HIV in sub-Saharan Africa and beyond.

Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program

BACKGROUND

In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation.

METHODS

We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned.

RESULTS

We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care.

CONCLUSIONS

This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting.

TRIAL REGISTRATION

ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.