Remote-Use Applications of the ALSFRS-R Clinical Outcome Assessment Tool: A Scoping Review

OBJECTIVES

In 2021, the U.S. Congress passed the ACT for ALS Act. The law encourages development of "tools, methods, and processes" to improve clinical trial efficiency for neurodegenerative diseases. The Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised (ALSFRS-R) is an outcome measure administered during in-person clinic visits and used to support investigational studies for persons living with Amyotrophic Lateral Sclerosis (PALS). Availability of a standardized, remote-use version of the ALSFRS-R may promote more inclusive, decentralized clinical trials. A scoping literature review was conducted to identify existing remote-use ALSFRS-R tools, synthesize feasibility and comparability of administration modes, and summarize barriers and facilitators to inform development of a standardized remote-use ALSFRS-R tool.

METHODS

Included studies reported comparisons between remote and in-person, clinician-reported, ALSFRS-R administration and were published in English (2002-2022). References were identified by searching peer-reviewed and gray literature. Twelve studies met inclusion criteria and were analyzed to compare findings within and across modes of administration.

RESULTS

Remote modes of ALSFRS-R administration were categorized into four non-mutually exclusive categories: telephone (n = 6), videoconferencing (n = 3), computer or online platforms (n = 3), mobile-apps and wearables (n = 2), and one unspecified telemedicine modality (n = 1). Studies comparing in-person to telephone or videoconferencing administration reported high ALSFRS-R rating correlations and nonsignificant between- mode differences.

CONCLUSION

There is insufficient information in the ALSFRS-R literature to support remote clinician administration for collecting high quality data. Future research should engage PALS, care partners and providers to develop a standardized remote-use ALSFRS-R version.

Friendship Bench Intervention to Address Depression and Improve HIV Care Engagement Among Adolescents Living with HIV in Malawi: Study Protocol for a Pilot Randomized Controlled Trial

Background

Adolescents in Sub-Saharan Africa are disproportionately affected by the HIV epidemic. Comorbid depression is prevalent among adolescents living with HIV (ALWH) and poses numerous challenges to HIV care engagement and retainment. We present a pilot trial designed to investigate feasibility, fidelity, and acceptability of an a dapted and an e nhanced F riendship B ench intervention (henceforth: AFB and EFB) in reducing depression and improving engagement in HIV care among ALWH in Malawi.

Methods

Design: Participants will be randomized to one of three conditions: the Friendship Bench intervention adapted for ALWH (AFB, n=35), the Friendship Bench intervention enhanced with peer support (EFB, n=35), or standard of care (SOC, n=35). Recruitment is planned for early 2024 in four clinics in Malawi.Participants: Eligibility criteria (1) aged 13-19; (2) diagnosed with HIV (vertically or horizontally); (3) scored ≥ 13 on the self-reported Beck's Depression Inventory (BDI-II); (4) living in the clinic's catchment area with intention to remain for at least 1 year; and (5) willing to provide informed consent.Interventions: AFB includes 6 counseling sessions facilitated by young, trained non-professional counselors. EFB consists of AFB plus integration of peer support group sessions to facilitate engagement in HIV care. SOC for mental health in public facilities in Malawi includes options for basic supportive counseling, medication, referral to mental health clinics or psychiatric units at tertiary care hospitals for more severe cases.Outcomes: The primary outcomes are feasibility, acceptability, and fidelity of the AFB and EFB assessed at 6 months and 12 months and compared across 3 arms. The secondary outcome is to assess preliminary effectiveness of the interventions in reducing depressive symptoms and improving HIV viral suppression at 6 months and 12 months.

Discussion

This pilot study will provide insights into youth-friendly adaptations of the Friendship Bench model for ALWH in Malawi and the value of adding group peer support for HIV care engagement. The information gathered in this study will lead to a R01 application to test our adapted intervention in a large-scale cluster randomized controlled trial to improve depression and engagement in HIV care among ALWH.

Trial registration

ClinicalTrials.gov Identifier NCT06173544.

Trajectories of intimate partner violence and their relationship to stress among young women in South Africa: An HPTN 068 study

BACKGROUND

One in four South African women will experience intimate partner violence (IPV) in their lifetime, potentially increasing their biological stress. In South Africa, limited IPV and stress research has utilized multiple timepoints or examined modifying factors. Cash transfers (CTs) are associated with reduced IPV and stress and may be an intervention target.

AIMS

We used data-driven methods to identify longitudinal IPV trajectory groups among South African adolescent girls and young women (AGYW), estimate each group's association with stress, and assess modification by a CT.

METHODS

A total of 2,183 South African AGYW ages 13 to 24 years from the HIV Prevention Trials Network 068 study were randomized to a CT or control group. Physical IPV was measured five times (2011-2017), and stress was captured once (2018-2019). Stress measures included the Cohen Stress Scale and stress biomarkers (C-reactive protein (CRP), cytomegalovirus (CMV), herpes simplex virus type-1 (HSV-1)). Group-based trajectory modeling identified IPV trajectories; ordinal logistic regression estimated the association between trajectory group and stress.

RESULTS

A two-group quadratic trajectory model was identified (higher trajectory group = 26.7% of AGYW; lower trajectory group = 73.3%). In both groups, the probability of IPV increased from ages 13 to 17 years before declining in early adulthood. However, the higher group's probability peaked later and declined gradually. The higher trajectory group was associated with an increased odds of elevated CRP (OR: 1.41, 95% CI [1.11, 1.80]), but not with other stress measures. The CT modified the relationship with CMV: a positive association was observed among the usual care arm (OR: 1.59, 95% CI [1.11, 2.28]) but not the CT arm (OR: 0.85, 95% CI [0.61, 1.19]).

CONCLUSIONS

Sustained IPV risk during adolescence was associated with elevated CRP in young adulthood. The relationship between IPV and elevated CMV was attenuated among those receiving a CT, suggesting that CTs could possibly reduce biological stress due to IPV.

Depression, Alcohol Use, and Sexual Behaviors by HIV Infection Stage and Diagnosis Timing Among STI Clinic Patients in Lilongwe, Malawi

Understanding depression, alcohol use, and sexual behaviors according to HIV infection stage and diagnosis timing is important for HIV prevention efforts. We enrolled persons with recent infection and diagnosis (i.e., acute HIV infection (AHI) (n = 92) persons newly diagnosed seropositive (n = 360)) and persons previously diagnosed with HIV (n = 190) into a randomized controlled trial in Lilongwe, Malawi (N = 641) and estimated the prevalence of probable depression (Patient Health Questionnaire-9 ≥ 5), hazardous alcohol use (Alcohol Use Disorder Identification Test-C: men ≥ 4; women ≥ 3), and sexual behaviors (transactional sex, condomless sex). Compared with previously diagnosed participants, participants newly seropositive and those with AHI reported a higher proportion of probable depression (7%, 27%, 38%; AHI/Previous: Table Probability: 0.02, p < 0.01; AHI/New: Table Probability: <0.01, p < 0.01), hazardous alcohol use (8%, 18%, 29%; AHI/Previous and AHI/New: Table Probability: <0.01, p < 0.01), and transactional sex (5%, 14%, 20%; AHI/Previous: Table Probability: <0.01, p < 0.01; AHI/New: Table Probability: 0.06, p = 0.24), respectively. HIV prevention services addressing mental health and alcohol misuse may be particularly beneficial for persons with recent HIV infection and or diagnosis.

Characterizing Network-Based HIV Testing Interventions to Guide HIV Testing and Contact Tracing at STI Clinics in Lilongwe, Malawi

BACKGROUND

Understanding heterogeneity across patients in effectiveness of network-based HIV testing interventions may optimize testing and contact tracing strategies, expediting linkage to therapy or prevention for contacts of persons with HIV (PWH).

SETTING

We analyzed data from a randomized controlled trial of a combination intervention comprising acute HIV testing, contract partner notification (cPN), and social contact referral conducted among PWH at 2 STI clinics in Lilongwe, Malawi, between 2015 and 2019.

METHODS

We used binomial regression to estimate the effect of the combination intervention vs. passive PN (pPN) on having any (1) contact, (2) newly HIV-diagnosed contact, and (3) HIV-negative contact present to the clinic, overall and by referring participant characteristics. We repeated analyses comparing cPN alone with pPN.

RESULTS

The combination intervention effect on having any presenting contact was greater among referring women than men [prevalence difference (PD): 0.17 vs. 0.10] and among previously vs. newly HIV-diagnosed referring persons (PD: 0.20 vs. 0.11). Differences by sex and HIV diagnosis status were similar in cPN vs. pPN analyses. There were no notable differences in the intervention effect on newly HIV-diagnosed referrals by referring participant characteristics. Intervention impact on having HIV-negative presenting contacts was greater among younger vs. older referring persons and among those with >1 vs. ≤1 recent sex partner. Effect differences by age were similar for cPN vs. pPN.

CONCLUSION

Our intervention package may be particularly efficacious in eliciting referrals from women and previously diagnosed persons. When the combination intervention is infeasible, cPN alone may be beneficial for these populations.

Synthesis of end-user research to inform future multipurpose prevention technologies in sub-Saharan Africa: a scoping review

Introduction

Women in sub-Saharan Africa (SSA) experience disproportionately high rates of HIV infection and unintended pregnancy compared to their age-matched counterparts in other regions of the world. Multipurpose prevention technologies (MPTs) that offer protection against HIV and unintended pregnancy in a single product stand to address these dual sexual and reproductive health needs simultaneously. The aim of this scoping review is to identify factors that are important for optimizing the likelihood of MPT adoption by end users in SSA.

Methods

Study inclusion criteria included MPT research (HIV and pregnancy prevention dual indication) published or presented in English from 2000 to 2022 and conducted in SSA amongst end-users (women aged 15-44), male partners, health care providers, and community stakeholders. References were identified by searching peer reviewed literature, grey literature, conference presentations (2015-2022), grant databases, and outreach to MPT subject matter experts. Of 115 references identified, 37 references met inclusion criteria and were extracted for analysis. A narrative synthesis approach was used to summarize findings within and across MPT products.

Results

Studies were identified from six countries in SSA and a substantial proportion included a South African (n = 27) and/or Kenyan (n = 16) study site. Most studies utilized a qualitative study design (n = 22) and evaluated MPT acceptability and preferences by presenting hypothetical products through images or a list of product attributes (n = 21). The vaginal ring (n = 20), oral tablet (n = 20), and injection (n = 15) were examined most frequently. Across studies, there was high acceptability and demand for an HIV and pregnancy prevention MPT. End users valued choice in prevention product type as well as discreetness and long-acting options. Provider counseling and community sensitization were reported as essential for future introduction of novel MPT delivery forms.

Conclusion

Recognizing the heterogeneity of women's preferences and changing reproductive and sexual health needs over the life course, choice is important in the delivery of pregnancy and HIV prevention products as well as amongst MPT products with distinct product profiles. End user research with active MPTs, vs. hypothetical or placebo MPTs, is necessary to advance understanding of end-user preferences and acceptability of future products.

HIV Related Behaviors Among Male Partners of Adolescent Girls and Young Women in Rural South Africa

Improving men's engagement in HIV prevention is not only essential for reducing their own HIV risk but also the risk of transmitting HIV to their female partners. We conducted a cross-sectional survey using a population-based sample of men (age 18-30) who reported being a partner of an adolescent girls and young women (AGYW) in South Africa (N = 2827). We used logit-binomial regression models to examine associations among men's partnership characteristics, HIV risk perceptions, and HIV-related behaviors and examine differences by male partner age (younger men (18-24) vs. older men (25-30)) and age difference between partners (age-concordant (< 5 years) vs. age-disparate (≥ 5 years)). Most men reported inconsistent condom use (85%) and nearly half reported engaging in transactional sex (48%). Older men were just as likely as younger men, and men with age-disparate and age-concordant partners, to inconsistently use condoms, engage in transactional sex, and perpetrate intimate partner violence. Most men also reported a very high interest in pre-exposure prophylaxis (PrEP) (77%) and half reported having an HIV test in the past year (50%). There were no differences by male partner age or age difference between partners in PrEP interest but older men and men in age-discordant relationships were more likely than younger men and men in age-concordant relationships to have an HIV test in the past year. Male partners of AGYW in South Africa are engaging in HIV-related behaviors and need HIV prevention interventions to reduce risk for themselves and their female partners.

Relationships Between Stress-Responsive Biomarkers, ART Adherence, and Viral Suppression Among Adolescent Girls and Young Women Living With HIV in South Africa: An HPTN 068 Analysis

BACKGROUND

Adolescent girls and young women (AGYW) living with HIV who have higher stress levels may be at risk of stress-related biological alterations, which could influence HIV progression and adherence to antiretroviral therapy (ART).

SETTING

We aimed to estimate associations among stress-responsive biomarkers, ART adherence, and viral suppression in AGYW living with HIV in South Africa. We also hypothesized that psychosocial stressors [eg, depression, food insecurity, low socioeconomic status (SES), and HSV-2] would be associated with higher biomarker levels.

METHODS

We used 2018/2019 data from the HIV Prevention Trials Network 068 cohort to assess associations between stress-responsive biomarkers and viral suppression (<1000 copies/mL) and ART adherence measured using dried blood spot cards. Stress-responsive biomarkers included C-reactive protein, herpes simplex virus type 1, and cytomegalovirus infection and reactivation. Associations were estimated using unadjusted log-binomial or ordinal logistic regression models.

RESULTS

In 166 AGYW living with HIV, there was no association between stress-responsive biomarkers and viral suppression or ART adherence. However, increased C-reactive protein levels were associated with higher HSV-2 infection [odds ratio (OR) 1.98; 95% confidence interval (CI) 1.11, 3.52], being a government grant recipient (OR 3.21; 95% CI: 1.30, 7.92), lower food insecurity (OR 0.34; 95% CI: 0.13, 0.90), and increased body mass index (OR 1.07; 95% CI: 1.01, 1.14).

CONCLUSIONS

High prevalence of psychosocial stressors and persistent herpesviruses in AGYW living with HIV has the potential to lead to poorer health outcomes. More research is needed to untangle relationships between economic stability, chronic disease, and chronic stress.

Couples' decision making regarding the use of multipurpose prevention technology (MPT) for pregnancy and HIV prevention

We conducted a secondary analysis of discrete choice experiment (DCE) data from 395 couples enrolled in the Microbicide Trials Network (MTN)-045/CUPID study in Uganda and Zimbabwe to understand couple decision making around choice of multipurpose prevention technologies (MPTs) to prevent both HIV and pregnancy. Members of couples completed the same DCE, first separately then jointly, choosing between two hypothetical MPTs in a series of nine questions. Most couples either had similar preferences at the outset or had equal decision-making around MPTs (62%). Couples with male influence (17%) were more likely to use contraceptive pills with a male partner's knowledge and couples with female influence (21%) were less likely to have shared decision making about family planning. Males influenced discussion around MPT duration, side effects, menstrual changes, and how the vagina feels during sex. Decision making was relatively shared, though decisions around certain attributes were more likely to be dominated by male partners.

Making the Case for Joint Decision-Making in Future Multipurpose Prevention Technology (MPT) Choice: Qualitative Findings on MPT Attribute Preferences from the CUPID Study (MTN-045)

Introduction

Young women in sub‐Saharan Africa account for two‐thirds of all new HIV infections and face high rates of unintended pregnancy. Multipurpose prevention technologies (MPTs) are promising products under development that are designed to simultaneously prevent HIV and unintended pregnancy. Since MPTs will be used in the context of sexual relationships, ensuring acceptability and use requires understanding the role of male partners in MPT use decision‐making.

Methods

This paper draws on qualitative data from 39 couples enrolled in the Microbicide Trials Network (MTN) 045 study, conducted in 2019–2020. Partners completed a discrete choice experiment (DCE), first separately and then jointly, to measure preferences for future MPT attributes and then completed a qualitative interview. We also draw on quantitative data from interviewer observation about who dominated the decision‐making process during the joint DCE. Content analysis was used to examine (1) how couples made decisions on existing non‐MPT HIV and pregnancy prevention products; (2) how couples made decisions on future ideal‐MPT product during the DCE; and (3) how these decision‐making processes varied by decision‐making dominance (10 male, 10 female and 19 equal) and interview type (19 joint and 20 separate).

Results

Existing non‐MPT product decisions focused on trust between partners and product attributes, while future ideal‐MPT product decisions exclusively focused on product attributes. Across existing and future products, preferences for product attributes varied by gender. Male partners were most concerned with limiting side effects impacting sexual pleasure, female partners were most concerned with limiting side effects causing physical symptoms and both were concerned with the return to fertility. Across all dominance and interview types, couples reported making decisions together and female partners were often able to negotiate with male partners for their preferred product or set of product attributes.

Conclusions

Research activities in this study provided an opportunity for couples to openly present their product attribute preferences to their partner, learn about their partner's attribute preferences, negotiate for their ideal set of attributes and ultimately choose attributes that benefited the couple without disempowering the female partner. Future research should focus on the utility of couple‐based decision‐making aids or similar tools for facilitating joint MPT decision‐making.

Partnership Dynamics and HIV-Related Sexual Behaviors Among Adolescent Mothers in South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data

PURPOSE

In South Africa, adolescent mothers have a three times higher risk of HIV acquisition than nonadolescent mothers. Yet, limited evidence exists regarding how early childbearing may affect HIV risk. A better understanding of adolescent mothers' partnership dynamics and sexual behaviors is critical to tailoring interventions to prevent new infections.

METHODS

Data are from HIV Prevention Trials Network 068, a longitudinal study of adolescent girls and young women (AGYW) aged 13-20 in South Africa who were followed annually for up to 6 years. Log-binomial regression models were used to assess whether adolescent motherhood was associated with partnership dynamics (intimate partner violence, gender inequitable norms, low relationship power, no HIV prevention communication) and if the association between partnership dynamics and sexual behaviors (unprotected sex and transactional sex) varied by adolescent motherhood. Generalized estimating equations, with an exchangeable correlation structure, were used to account for nonindependence.

RESULTS

Adolescent mothers were more likely than nonadolescent mothers to be in partnerships characterized by intimate partner violence, low relationship power, gender inequitable norms, and no HIV prevention communication. A higher proportion were also more likely to experience these dynamics, as well as engage in transactional sex, after giving birth. Poor partnership dynamics put AGYW at a higher risk for unprotected sex and transactional sex, regardless of adolescent motherhood status.

DISCUSSION

Engaging adolescent mothers in interventions post birth and developing interventions that address power imbalances in AGYW's sexual partnerships have the potential to reduce engagement in HIV-related sexual behaviors and HIV risk in the long term.

Probable perinatal depression and social support among women enrolled in Malawi's Option B+ Program: A longitudinal analysis

BACKGROUND

Malawi's PMTCT Option B+ program has expanded the reach of ART services among pregnant and breastfeeding women, but retention in lifelong HIV care remains challenging. Given that depression can undermine retention, it is important to understand how depression changes over the perinatal period, varies across treatment and retention groups, and could be buffered by social support.

METHODS

Data are from an observational study conducted among women enrolled in Malawi's PMTCT Option B+ program. We used multilevel generalized linear models to estimate the odds of probable depression by time, treatment and retention group, and social support. Probable depression was assessed with the Edinburgh Postnatal Depression Scale and Patient Health Questionnaire-9.

RESULTS

Of 468 women, 15% reported probable depression at antenatal enrollment and prevalence differed across newly diagnosed individuals, second line therapy users, and previous defaulters (18%, 21%, 5%, p = 0.001). Odds of probable perinatal depression decreased over time (OR per month: 0.87, 95% CI: 0.82-0.92) but were higher among those newly diagnosed (OR: 3.25, 95% CI: 1.59-6.65) and on second line therapy (OR: 3.39, 95% CI: 1.44-7.99) as compared to previous defaulters. Odds of probable postpartum depression were lower for participants with high social support (OR: 0.19, 95% CI: 0.09-0.39).

LIMITATIONS

Lack of diagnostic psychiatric evaluation precludes actual diagnosis of depression.

CONCLUSIONS

Probable depression varied across the perinatal period and across treatment and retention groups. Social support was protective for postpartum depression among all participants. Depression screening and provision of social support should be considered in PMTCT programs.

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.

Effects of Early Social Bonds on Adolescent Trajectories of Sexual Risk Behaviors Among South African Girls

The goal of this manuscript is to advance HIV risk behavior prevention efforts for South African adolescent girls by identifying distinct trajectory patterns across multiple behavioral domains for adolescent and young adults. We draw from a sample of N = 1070 adolescent girls from South Africa who were between the ages of 13-15 at baseline. Participants were followed across 6 waves of data collection between 2011 and 2019. We focus on predicting trajectories between ages 15 and 21. All participants were HIV negative and had not experienced sexual debut at baseline. We examine group-based multi-variable trajectories across several known HIV risk behaviors: earlier age of sexual debut, engaging in unprotected sex, engaging in transactional sex, earlier age at first pregnancy, and exposure to physical IPV. We characterized three prototypical joint trajectories: abstainers (54%), early unprotected sex (36%), and high-risk sexually active (11%). We then predicted membership based on the following baseline risk and protective factors: household expenditures, bonding to school, parental monitoring, number of close friends, and community engagement. We found that school bonding and parental monitoring were the strongest predictor of sexual risk, and that, among those in both the early unprotected sex and high-risk groups, risky behaviors like unprotected and transactional sex most frequently occurred early in adolescence. These findings suggest that interventions should target girls early in adolescence, and that interventions focused at improving school bonding and promoting parental involvement may be most effective at preventing risky sexual behavior.

HIV and Herpes Simplex Virus Type 2 Incidence Among Adolescent Mothers in South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data

BACKGROUND

Adolescent motherhood is common in South Africa and occurs against a backdrop of high HIV risk. While childbearing during adolescence may result in social and economic strain that may negatively impact health, there has been limited study of whether adolescent motherhood increases the risk of HIV or herpes simplex virus type 2 (HSV-2) acquisition or engagement in high-risk sexual partnerships.

SETTING

Data are from HIV Prevention Trials Network 068, a longitudinal conditional cash transfer study of adolescent girls and young women (age, 13-23) in rural South Africa.

METHODS

We used survival analysis to estimate hazard ratios to determine if adolescent motherhood (live birth before 20 years) predicted incident HIV and incident HSV-2 and generalized estimating equations for behavioral risk ratios to determine if adolescent motherhood was associated with transactional sex and age-disparate partnerships.

RESULTS

Of 2452 adolescent girls and young women who were HIV negative at baseline, 5% were adolescent mothers; 16% were adolescent mothers by the end of the study period. After controlling for covariates, adolescent motherhood predicted incident HSV-2 acquisition [ adjusted hazard ratios, 1.30; 95% confidence interval (CI): 1.01 to 1.95] but not HIV acquisition ( adjusted hazard ratios, 1.19; 95% CI, 0.76 to 1.86). Adolescent motherhood was also associated with being in an age-disparate partnership (adjusted risk ratio, 1.30; 95% CI: 1.07 to 1.58) but not transactional sex.

CONCLUSION

Adolescent motherhood increased the risk of HSV-2 and engagement in age-disparate partnerships, both known risk factors for HIV infection. Sexually transmitted infection screening and/or tailored combination HIV prevention interventions that account for the context of adolescent motherhood are critical to maximize adolescent mothers' long-term health and to meet UNAIDS 95-95-95 targets by 2030.

Contraceptive Conversations among Adolescent Girls and Young Women and Their Partners, Peers, and Older Female Family Members in Lilongwe, Malawi: A QualitativeAnalysis

In sub-Saharan Africa, adolescent girls and young women (AGYW) have high levels of unmet need for contraception, particularly those who are unmarried or nulliparous. Conversations with partners, peers, and family members influence AGYW contraceptive decision-making yet little is known about conversation content and impact or how they vary by relationship status and parity. This paper draws on qualitative data from 60 AGYW (aged 15-24) participating in a sexual and reproductive health study in Malawi to examine contraceptive conversation patterns among participants and their social ties. AGYW's relationship status and parity influenced whether they talked about contraceptives, who they talked to about contraceptives, and the type of contraceptives that were endorsed during conversations. Unmarried and nulliparous AGYW were less likely to discuss contraceptives with all social ties and when conversations occurred, norms and misinformation regarding nonbarrier methods were reinforced, and condoms were largely prescribed. Conversations with intimate partners often provided permission for contraceptive use while conversations with peers and older women in the family provided information on contraceptive methods. Our results highlight the unique roles that social ties play in AGYW contraceptive decision-making and suggest that existing contraceptive conversation patterns might exclude unmarried, nulliparous AGYW from accurate and comprehensive contraceptive information and options.

Complementarity of Digital Health and Peer Support: “This Is What’s Coming”

Purpose

This study examined integration of peer support and a Food and Drug Administration-cleared, diabetes management app (DMA) in diabetes self-management support as a scalable model for those with type 2 diabetes mellitus (T2DM).

Methods

Two lay health Coaches delivered telephone-based self-management support to adults (N = 43) with T2DM recruited through a primary group practice. Those eligible were offered no-cost access to DMA for the entire 6-month study. Coaches introduced DMA and contacted individuals by phone and text with frequency dependent on participant needs/preferences. DMA supported monitoring of blood glucose, carbohydrate intake, and medication use, as well as messaging personalized to participants’ medication regimens. Clinical data were extracted from DMA, electronic medical records, and Coaches’ records. Structured interviews of 12 participants, 2 Coaches, and 5 project staff were analyzed using deductive pre-identified codes (regarding adoptability, patterns of use, value added, complementarity, and sustainability) utilizing standard procedures for qualitative analysis.

Results

Of the 43 participants, 38 (88.4%) enrolled in DMA. In general, participants used both DMA and lay health coaches, averaging 144.14 DMA entries (structured, e.g., medications, and free form, e.g., “ate at a restaurant” and “stressed”) and 5.86 coach contacts over the 6-month intervention. Correlation between DMA entries and coach contacts (r = .613, p &lt; 0.001) was consistent with complementarity as were participants’ and coaches’ observations that (a) DMA facilitated recognition of patterns and provided reminders and suggestions to achieve self-management plans, whereas (b) coaching provided motivation and addressed challenges that emerged. Mean hemoglobin A1c (A1c) declined from 9.93% to 8.86% (p &lt; 0.001), with no pattern of coaching or DMA use significantly related to reductions. Staff identified resources to coordinate coach/DMA interventions as a major sustainability challenge.

Conclusions

DMA and peer support for diabetes management are compatible and complementary. Additional practice integration research is needed for adoption and scale-up.

Community Space, Community Groups, and Incident HIV Infection Among Adolescent Girls and Young Women in Rural South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data

BACKGROUND

As adolescent girls and young women (AGYW) transition to adulthood, their interaction with their social context becomes a critical consideration for HIV prevention interventions. Few studies have examined what types of community groups and community spaces might be protective for AGYW HIV acquisition and related sexual behaviors.

METHODS

Data were obtained from HIV Prevention Trials Network 068, a longitudinal study of AGYW (age 13-20 years) in rural South Africa. Survival analyses and generalized estimating equations were used to assess whether community group membership and time spent in community spaces were associated with HIV incidence and sexual behaviors (unprotected sex, transactional sex, and having an older partner).

RESULTS

A total of 2245 AGYW were followed up for up to 4 years. Membership in church groups [adjusted hazard ratio (aHR): 0.75, 95% confidence interval (CI): 0.53 to 0.91] and dance groups (aHR: 0.89, 95% CI: 0.80 to 0.98) and spending time at church (aHR: 0.88, 95% CI: 0.79 to 0.98) were protective for HIV infection. Conversely, spending time at taverns was associated with higher HIV incidence (aHR: 1.27, 95% CI: 1.15 to 1.41). Membership in church groups and spending time at a family member's home and at church were protective for all 3 sexual behaviors. Spending time at a boyfriend's home and taverns was risky for all 3 sexual behaviors.

CONCLUSIONS

The results suggest that community spaces and community groups that include an element of adult supervision are potentially protective, whereas spaces and groups that provide an opportunity for AGYW to interact unsupervised with boyfriends or meet new partners are potentially risky.

The mediating role of partner communication on contraceptive use among adolescent girls and young women participating in a small-group intervention in Malawi: A longitudinal analysis

Though effective reproductive health interventions have been developed for adolescent girls and young women (AGYW) in sub-Saharan Africa, few have explored whether specific components of the interventions are responsible for observed changes in behaviour. Data for this longitudinal mediation analysis come from a quasi-experimental, sexual and reproductive health study conducted among AGYW (age 15-24) in Malawi. We assessed the extent to which the relationship between attending communication-specific small-group sessions and contraceptive use at one-year was mediated by contraceptive communication with partners at six months, using a bootstrapping procedure to estimate indirect effects. Of 358 participants, 44% attended communication-specific small-group sessions, 37% communicated with partners about contraception at six months, and 21% used non-barrier contraception at one-year. Participants who attended communication-specific small-group sessions had increased contraceptive communication with partners at six months (aOR = 1.48, 95% CI: 1.07-2.38) and increased non-barrier contraceptive use at one-year (aOR = 3.53, 95% CI: 1.86-6.69). The relationship between attending communication-specific small-group sessions and non-barrier contraceptive use at one-year was partially mediated by contraceptive communication with partners at six months (indirect effect = 0.04, 95% CI: 0.01-0.07). Our results suggest that contraceptive communication with partners is modifiable through interventions and important for AGYW non-barrier contraceptive uptake.

Communication, social norms, and contraceptive use among adolescent girls and young women in Lilongwe, Malawi

In Malawi, 50% of adolescent girls and young women (AGYW) have had a first child by age 19 and 45% report their pregnancies as unintended or mistimed. Yet, uptake of contraception remains low. Understanding how interactions with social ties impact AGYW contraceptive use might explain low uptake beyond individual and environmental factors. Data are from Girl-Power, a study among sexually active AGYW, aged 15-24, in Malawi. We used logistic regression models to examine whether contraceptive communication and social norms (descriptive and injunctive) were associated with contraceptive use (non-barrier methods and condoms) and how associations differed across social ties (older women in the family, peers, and partners). The sample included 942 participants: 28% reported using non-barrier methods and 66% reported using condoms. Contraceptive communication with older women in the family (aOR: 1.48, 95% CI: 0.99, 2.20), peers (aOR: 3.12, 95% CI: 1.96, 4.96), and partners (aOR 5.15, 95% CI: 3.13, 8.48) was associated with non-barrier method use. Descriptive norms were associated with non-barrier methods among peers (aOR 2.57, 95% CI: 1.63, 4.96) but not among older women in the family (aOR: 1.22, 95% CI 0.80, 1.88). There were no associations among contraceptive communication, social norms, and condom use across older women in the family, peers, and partners. The findings highlight the need to consider the influence of social ties in the design of future family planning interventions and suggest that interventions that encourage interpersonal communication about contraception and target peer-based descriptive norms have the potential to impact uptake of non-barrier methods.

The association between social support through contacts with Accredited Social Health Activists (ASHAs) and antenatal anxiety among women in Mysore, India: a cross-sectional study

PURPOSE

In India, antenatal anxiety prevalence estimates range from 6 to 48%. Social support is strongly associated with mental wellbeing, yet most studies have examined the impact of support from partners and family members rather than peers, community members, or health care providers. This study explores the supportive role of Accredited Social Health Activists (ASHA) contacts for antenatal anxiety.

METHODS

Data were analyzed from the Saving Children, Improving Lives project, a quasi-experimental study conducted among rural, pregnant women in India. Regression models were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals for the relationship frequency of ASHA contacts and antenatal anxiety. Antenatal anxiety was measured using a subscale of the Edinburgh Postnatal Depression Scale.

RESULTS

The sample consisted of 480 pregnant women. Reported antenatal anxiety prevalence was 27% (95% CI 23%, 31%). Participants who were more frequently visited by ASHAs at home (aPR: 0.90; 95% CI 0.76, 0.98) and more frequently accompanied by ASHAs to their antenatal care visits (aPR: 0.86, 95% CI 0.78, 0.95) were less likely to report antenatal anxiety. ASHA home visits were protective for the most vulnerable women (primigravida and those experiencing domestic violence) and ASHA accompaniment to antenatal care visits was equally protective for all women.

CONCLUSIONS

ASHAs are valued for their contribution towards maternal health education and linking women of reproductive age to healthcare services. Our findings additionally suggest the important role ASHAs play in providing social support to pregnant women, particularly those who are most vulnerable to experiencing antenatal anxiety.

Assessing the Impact of a Small-Group Behavioral Intervention on Sexual Behaviors Among Adolescent Girls and Young Women in Lilongwe Malawi: A Quasi-Experimental Cohort Study

Adolescent girls and young women (AGYW) in sub-Saharan Africa are at high risk of many adverse sexual and reproductive health outcomes. Small-group interventions addressing underlying vulnerabilities may influence risky sexual behaviors associated with these adverse outcomes. Girl Power-Malawi assessed whether a facilitator-led, curriculum-driven small-group behavioral intervention impacted risky sexual behaviors among AGYW in Lilongwe, Malawi. Four Health Centers were selected; two were randomly assigned to provide the intervention. Two-hundred fifty AGYW 15-24 years old were enrolled in each clinic (N = 1000 total), followed for 1 year, and interviewed at baseline and endline. At both time points participants reported on two behaviors in the last month (vaginal sex and ≥ 2 sexual partners) and two behaviors in the last year (age-disparate relationships and transactional relationships). In intervention clinics, there were no declines in risk behaviors between baseline and endline. Endline behaviors were not less risky in intervention clinics than control clinics. This intervention did not have a positive effect on four risk behaviors over a 1-year period.

The impact of HIV couple testing and counseling on social support among pregnant women and their partners in Lilongwe, Malawi: an observational study

Couples HIV testing and counseling (couple counseling) promotes safer sexual behaviors, increases communication between couples, and decreases HIV transmission. However, the impact of couple counseling on social support, critical for persons living with HIV, has not been examined. Ninety couples with a recently tested HIV-positive pregnant woman (female-positive couples) and 47 couples with a recently tested HIV-negative pregnant woman (female-negative couples) were enrolled in an observational study at an antenatal clinic in Malawi. Each couple member was assessed immediately before and one month after couple counseling for partner, family, and peer social support using the Multidimensional Scale of Perceived Social Support. Before couple counseling, social support was lower among women than men in both female-positive couples (β = -10.00, p < .01) and female-negative couples (β = -8.43, p  < .01). After couple counseling, social support increased for women in female-positive couples (β = 4.01, p < .01) and female-negative couples (β = 4.69, p < .01) but not for men in either type of couple. Couple counseling could be an effective strategy to increase social support for women, including those with recent HIV diagnoses.

Task shifting levonorgestrel implant insertion to community midwife assistants in Malawi: results from a non-inferiority evaluation

BACKGROUND

In 2013, Malawi began task shifting long acting reversible contraception (LARC) insertion from Nurse Midwife Technicians (NMTs), who undergo 3 years of training, to Community Midwife Assistants (CMAs), who undergo 18 months of training. However, there is no evidence on whether CMAs have the same competency as NMTs for LARC insertion. Therefore, we describe a non-inferiority evaluation to determine whether CMAs are non-inferior to NMTs for the insertion of levonorgestrel (LNG) contraceptive implants in Malawi.

METHODS

One CMA and one matched NMT from 31 health centers across Malawi were selected for training in Malawi's 1-week LARC insertion course in October 2016, and 31 CMAs and 30 NMTs completed the training. After the course, two Family Planning Master Trainers visited the nurses' health centers over a 5-month period and used the Malawi LNG implant insertion checklist to evaluate the first five LNG implant insertions that each nurse performed during the monitoring visit. A non- inferiority margin of 10% was used to compare mean implant scores between CMAs and NMTs.

RESULTS

We were able to fully evaluate 29 CMAs and 29 NMTs with the LNG implant insertion checklist. The CMAs and NMTs had mean scores of 90.2% and 89.7%, respectively, which were non-inferior (mean difference - 0.5%; 95% CI -3.4%, 2.4%), even when adjusted for the number of years post-graduation and the number of LNG implants inserted pre-training, during training, and since training (mean difference 1.3%; 95% CI -2.2%, 4.8%).

CONCLUSIONS

CMAs were non-inferior to NMTs with LNG implant insertion, and both cadres were generally observed to be competent with their insertions after completing their follow-up evaluations. During the evaluations, we generally saw an increase in scores with each insertion. Therefore, for both cadres, it is important to establish continued mentorship and evaluation for LARC insertion after the initial training.

Adjusting ferritin concentrations for inflammation: Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Background: The accurate estimation of iron deficiency is important in planning and implementing interventions. Ferritin is recommended as the primary measure of iron status, but interpretability is challenging in settings with infection and inflammation.Objective: We assessed the relation between ferritin concentrations and inflammation and malaria in preschool children (PSC) (age range: 6-59 mo) and women of reproductive age (WRA) (age range: 15-49 y) and investigated adjustment algorithms to account for these effects.Design: Cross-sectional data from 15 surveys for PSC (n = 27,865) and 8 surveys for WRA (24,844), from the Biomarkers Reflecting the Inflammation and Nutritional Determinants of Anemia (BRINDA) project were analyzed individually and combined with the use of a meta-analysis. Several approaches were explored to estimate depleted iron stores (ferritin concentration <12 μg/L in PSC and <15 μg/L in WRA) in inflammation and malaria settings as follows: 1) increase ferritin-concentration cutoff to <30 μg/L; 2) exclude individuals with C-reactive protein (CRP) concentrations >5 mg/L or α-1-acid glycoprotein (AGP) concentrations >1 g/L; 3) apply arithmetic correction factors; and 4) use a regression correction approach.Results: Depleted iron-store estimates incrementally increased as CRP and AGP deciles decreased (4% compared with 30%, and 6% compared with 29% from highest compared with lowest CRP deciles for pooled PSC and WRA, respectively, with similar results for AGP). Depending on the approach used to adjust for inflammation (CRP plus AGP), the estimated prevalence of depleted iron stores increased by 7-25 and 2-8 absolute median percentage points for PSC and WRA, respectively, compared with unadjusted values. Adjustment for malaria in addition to CRP and AGP did not substantially change the estimated prevalence of depleted iron stores.Conclusions: Our results lend support for the use of internal regression correction to estimate the prevalence of depleted iron stores in regions with inflammation. This approach appears to mathematically reflect the linear relation of ferritin concentrations with acute-phase proteins. More research is warranted to validate the proposed approaches, but this study contributes to the evidence base to guide decisions about how and when to adjust ferritin for inflammation.