Factors influencing neonatal male circumcision uptake among expecting couples in Zambia: formative findings

Male circumcision is a protective HIV prevention strategy. However, uncircumcised Zambian men are reluctant to undergo voluntary medical male circumcision (VMMC). Tailored interventions are necessary to stimulate the uptake of early infant male circumcision (EIMC) and VMMC in Zambia. This feasibility study presents the formative process of utilising the PRECEDE framework in the development of a family-centred EIMC/VMMC intervention, Like Father Like Son, and its application in an existing VMMC intervention, Spear & Shield. We found that fear of the pain associated with EIMC procedures, foreskin disposal, beliefs in children's autonomy and rights, and men's dominance in health decision-making were factors affecting EIMC uptake. Perceived benefits for infants included improved hygiene, protection from HIV infection, and faster recovery. Reinforcing factors included female partners and fathers' MC status. The availability and access to EIMC services and information, skill and experience of health workers, and engagement and belief in traditional circumcision practices were factors enabling EIMC uptake. These individual, interpersonal, and structural factors positively and negatively influencing EIMC uptake in the Zambian clinic context were integrated into the intervention for expecting parents. Feedback from community advisory boards suggested the process was effective in developing a culturally tailored and acceptable EIMC/VMMC promotion intervention.

Dissemination and implementation of an evidence-based voluntary medical male circumcision program: The Spear & Shield program

Despite compelling evidence linking voluntary medical male circumcision (VMMC) with 60-70% HIV risk reduction in sub-Saharan Africa, Zambian men have been especially reluctant to undergo VMMC. The Government of Zambia set targets for VMMC uptake and promoted community-level interventions. Spear & Shield (S&S) is an innovative, evidence-based, service program promoting VMMC uptake while ensuring both VMMC supply and demand. This study assessed the large-scale provincial rollout of the program (S&S2) utilizing the RE-AIM model for translating interventions into the community. The S&S2 study was conducted between November 2015 and December 2020, and sequentially rolled out over four Zambian provinces in 96 clinics; 24 observation clinics received VMMC training only. Local clinic healthcare workers were trained to conduct the VMMC procedure and HIV counselors were trained to lead S&S group sessions. Using the RE-AIM model, primary outcomes were: Reach, the number, proportion, and representativeness of S&S attendees; Effectiveness, the impact of S&S2 on VMMC uptake; Adoption, the number, proportion, and representativeness of clinics implementing S&S2; Implementation, fidelity to the S&S intervention manual; and Maintenance, the extent to which S&S2 became an element of standard care within community clinics. Initially, n = 109 clinics were recruited; 96 were sustained and randomized for activation (Adoption). A total of 45,630 clinic patients (n = 23,236 men and n = 22,394 women) volunteered to attend the S&S sessions (Reach). The S&S2 program ran over 2,866 clinic-months (Implementation). Although the study did not target individual-level VMMCs, ~58,301 additional VMMCs were conducted at the clinic level (Effectiveness). Fidelity to the S&S intervention by group leaders ranged from 42%-95%. Sustainability of the program was operationalized as the number of CHCs initially activated that sustained the program. Intervention delivery ended, however, when study funding ceased (Maintenance). The S&S2 program successfully utilized the RE-AIM model to achieve study goals for implementation and dissemination in four Zambian provinces. Innovative VMMC programs such as S&S2 can improve the uptake of VMMC, one of the most effective strategies in the HIV prevention arsenal.

Increasing early infant male circumcision uptake in Zambia: Like father like son

Voluntary Medical Male Circumcision (VMMC) is an effective strategy for HIV prevention in areas with high prevalence of, and risk for, HIV. More than 361,000 male neonates are born each year in Zambia, many of whom could be eligible for Early-Infant Medical Circumcision (EIMC). Building on successful implementation strategies utilized in our Spear & Shield program, this pilot study, "Like Father, Like Son" (LFLS), evaluated the feasibility and acceptability of offering combined EIMC and VMMC services and couple-level behavioral interventions. A total of N = 702 pregnant women and their male partners (n = 351 couples) were recruited and enrolled. Couples were assessed twice pre-birth, 2 weeks post birth, and 6 months post birth. Expectant mothers were an average of 15.05 weeks pregnant (SD = 8.83). Thirty-nine pregnancies did not result in a live birth (11%), 14 couples withdrew from the study or were lost to follow-up prior to delivery (4%), and 148 babies were born female (42%), leaving 150 couples with a male infant in the analytic sample (43%). The LFLS study achieved significantly higher EIMC rates (35%) in comparison with previously observed EIMC study rates in Zambia (11%), and significantly higher than hypothetical comparison rates up to 30%. Relative to baseline rates, odds of VMMC among couples' older sons increased by 31% at post-intervention and by 90% at two-weeks following birth. Overall, this pilot study found the LFLS intervention to be feasible, acceptable, and effective in doubling the rate of EIMC in comparison with a previous longitudinal study in Zambia. Future research should consider a family-centric approach to promotion of male circumcision for infants and adolescents. LFLS may be effective in promoting father-son "bonding" by MC status; a bond that may be a bridge to increase both EIMC and VMMC uptake in newborns and couples' older sons and is a novel leverage point for promotion of this HIV prevention strategy.

Psychological and physical intimate partner violence and sexual risk behavior among South African couples: a dyadic analysis

This study aimed to examine intimate partner violence (IPV) as it relates to both partners' perceptions of IPV and sexual behaviors, considering how their IPV might be interdependent within the relationship dynamics. The sample consisted of 713 female-male dyads in which women were pregnant and living with HIV in rural South Africa. Using an actor-partner interdependence model (APIM), we examined the interdependent influence of psychological and physical IPV on men by their female partners and psychological and physical IPV on women by their male partners on sexual risk behavior. The APIM model found there were no actor (b = -0.06, SE = 0.05, p = .221) or partner (b = -1.2, SE = 0.06, p = .056) effects contributing to protected sex by female IPV victimization. In contrast, significant actor (b = -0.28, SE = 0.06, p < .001) and partner (b = -0.29, SE = 0.06, p < .001) effects for protection were related to male IPV victimization. The model also found that the covariate of female HIV disclosure was associated with both male (b = 0.5, SE = 0.12, p < .001) and female protected sexual intercourse (b = 0.58, SE = 0.1, p < .001). Female HIV disclosure was related to an increased likelihood of protected sex by both male and female partners. As male partners reported more IPV victimization, the likelihood of protected sex between male and female partners decreased.Trial registration: ClinicalTrials.gov identifier: NCT02085356.

A small cluster randomised clinical trial to improve health outcomes among Argentine patients disengaged from HIV care

Background

Patients disengaged from HIV care, e.g., missed medication pick-ups, not attending physician visits, account for ≥70% of new HIV infections. Re-engaging and sustaining engagement is essential to controlling the HIV pandemic. This study tested a physician-delivered evidence-based intervention, Motivational Interviewing (MI), to improve health outcomes, adherence to antiretroviral therapy (ART), HIV virologic suppression, CD4+ count, retention in HIV care, and self-efficacy among patients disengaged from care in Argentina.

Methods

Regional clinics (n = 6) were randomised to condition, MI Intervention or Enhanced Standard of Care (ESOC), and recruited N = 360 patients disengaged from HIV care. ART adherence, HIV RNA viral load, CD4+ count retention, and self-efficacy were assessed at baseline, 6, 12, 18, and 24-months. Indirect effects from condition to main outcomes were examined using patient-provider relationship as a mediator. The study was a cluster-randomised clinical trial entitled Conexiones y Opciones Positivas en la Argentina 2 (COPA2) and was registered at clinicaltrials.gov, NCT02846350.

Findings

Participants were an average age of 39·15 (SD = 10·96), 51% were women; intervention participants were older (p = ·019), and more ESOC participants were women (60% vs. 42%, p = 0·001). Using mixed models, the intervention had no effect on ART adherence over time by condition on HIV RNA viral load, CD4+ count retention, or self-efficacy. However, analysing mediated paths, there was an indirect effect of condition on ART adherence (B = 0·188, p = 0·009), HIV viral load (B = -0·095, P = 0·027), and self-efficacy (B = 0·063, P = 0·001), suggesting the intervention was associated with improved patient-provider relationships, which was in turn associated with increased ART adherence, lower HIV viral load, and higher self-efficacy.

Interpretation

These findings suggest that physician-delivered MI may enhance the patient-provider relationship, self-efficacy, and ART adherence, and reduced HIV viral load in patients disengaged from HIV care. However, these findings are preliminary due to the small number of clusters randomised, and replication is warranted.

Funding

National Institutes of Health.

Dissemination of the Spear & Shield Project using a Training of Trainers Model: A reflection on challenges and successes

Several large-scale clinical trials have conclusively demonstrated that voluntary medical male circumcision (VMMC) could provide a 50%-70% reduction in HIV acquisition, but willingness to undergo VMMC has been lowest in Zambia compared to other countries in eastern and southern Africa. This manuscript describes training for "task-shifting" among local healthcare workers at Community Health Centers (CHCs) applying state of the art strategies (e.g., Training of Trainers, i.e., ToT, and Training of Facilitators, ToF) to provide novel clinical services. Staff at 96 CHCs from four Provinces in Zambia were sequentially trained to provide the Spear & Shield intervention. A total of 45,630 men (n = 23,236) and women (n = 22,394) volunteered to participate in the S&S intervention service program when offered in the CHCs. Group session (total = 5313 sessions; 2,736 men's and 2,582 women's sessions) were conducted over 4.5 years. Remarkably, both men and women's groups achieved 97% retention. Of these, 256 sessions recorded from 128 group leaders were assessed and scored for intervention fidelity; fidelity was 80%-90% among the majority of clinics. S&S program sustainment exceeded expectations among 85% of clinics (82/96) in all provinces across the duration of the study. Of note, attendance in the S&S program was encouraged by CHC staff, but no financial incentives were provided to those attending S&S. This study examined the effectiveness of the ToT/ToF model in dissemination of the S&S program, which proved to be feasible even in resource-limited settings. Benefits and challenges are discussed.

Understanding barriers and facilitators to voluntary medical male circumcision and Spear and Shield uptake in Zambian community health centers

Voluntary medical male circumcision (VMMC) has been an effective method for reducing the risk of HIV transmission by 50%-70% in Eastern and Southern Africa. The Spear and Shield (S&S) program is a community health center (CHC)-based biobehavioral VMMC HIV prevention intervention that increased VMMC uptake in male CHC attendees in Lusaka, Zambia. Qualitative data organized using the Consolidated Framework for Implementation Research (CFIR) has been used to characterize factors that may impact S&S/VMMC implementation. This manuscript uses the CFIR to examine S&S implementation across 96 CHCs in four Zambian provinces using a mixed-methods approach to (a) quantify successful S&S implementation; (b) understand how CFIR domains might provide insight into the degree of implemental success; (c) identify major themes among least and most successful CHCs; and (d) help guide future prevention efforts and policy related to VMMC promotion in the Zambian CHC context. In contrast with CFIR quantitative analyses, 12 major qualitative themes associated with the least and most successful CHCs provided unique insight into S&S and VMMC implementation and guidance for future implementation studies. Themes included lack of resources (staff, space, transportation) for the former and strong staff relationships and active community engagement for the latter. The CFIR framework appears extremely useful for the identification of qualitative themes related to intervention implementation, and reduction of qualitative data for quantitative analyses may sacrifice more nuanced information. Consideration of CFIR themes may be useful to inform HIV prevention strategies in Zambia and similar contexts.

Blood Pressure, Depression, and Suicidal Ideation Among Pregnant Women with HIV

Although prior research has examined associations between blood pressure (BP), depression, and suicidal ideation, few studies have examined this in high-risk populations such as pregnant women with HIV (WHIV). The current study examined the association of BP with depression and suicidal ideation among pregnant WHIV (n = 217) in rural South Africa. BP data (measured ≤ 1 month before the study visit) was extracted from medical records. Depressive symptomatology and suicidal ideation were assessed using the Edinburgh Postnatal Depression Scale. Diastolic BP was positively associated with both suicidal ideation and depressive symptomatology, even after controlling for demographic variables, gestational age, and intimate partner violence. These findings suggest that WHIV with elevated BP may be at greater risk for antenatal depression and suicidal ideation. Future research should utilize longitudinal designs to examine potential mechanisms and the directionality of the relationship, as well as other contributing factors.

Photonic metacrystal: design methodology and experimental characterization

We report a design methodology for creating high-performance photonic crystals with arbitrary geometric shapes. This design approach enables the inclusion of subwavelength shapes into the photonic crystal unit cell, synergistically combining metamaterials concepts with on-chip guided-wave photonics. Accordingly, we use the term "photonic metacrystal" to describe this class of photonic structures. Photonic metacrystals exploiting three different design freedoms are demonstrated experimentally. With these additional degrees of freedom in the design space, photonic metacrystals enable added control of light-matter interactions and hold the promise of significantly increasing temporal confinement in all-dielectric metamaterials.

Examining Factors Associated with Gender Identity Among Individuals Disengaged from HIV Care in Argentina

BACKGROUND

Transgender women (TGW) consistently show lower adherence to antiretroviral treatment (ART), than cisgender people (CP) living with HIV. This study examined sociodemographic and psychosocial factors associated with gender identity among individuals disengaged from HIV care in Argentina.

METHODS

Data for this study was obtained at baseline from the Conexiones y Opciones Positivas en la Argentina 2 (COPA2) study. Forty-one TGW and 360 CP (177 male, 183 female) disengaged from HIV care completed questionnaires assessing sociodemographic information, severity of depressive symptoms, substance and alcohol use, patient-provider relationship quality, self-efficacy, ART adherence motivation, self-reported adherence, and treatment-related factors. Analyses included chi-square tests exploring the association between categorical variables and gender identity, and ANCOVAs comparing groups controlling for age.

RESULTS

Being a TGW was associated with having only public health insurance; substance use, particularly cocaine; substance-related problems; and hazardous drinking. TGW showed more negative consequences related to substance use, more hazardous alcohol use, lower patient-provider relationship quality, and lower self-reported adherence, than CP.

CONCLUSIONS

Harm reduction should be a key component in HIV care for TGW to address substance use. Health care teams should receive formal training in patient-provider communication skills and trans-specific competencies to enhance TGW's adherence and retention. Public policies to address structural factors that negatively affect TGW's adherence to ART are also needed.

Identifying factors associated with successful implementation and uptake of an evidence-based voluntary medical male circumcision program in Zambia: the Spear and Shield 2 Program

Voluntary medical male circumcision has been shown to provide a 50%-70% reduction in the risk of HIV infection without contributing to behavioral disinhibition of safer sexual practices. This study examined the interim implementation and dissemination data of Spear and Shield 2, an HIV risk-reduction program in Zambia. The purpose of this interim review was to identify contextual challenges to implementation and implement midcourse corrections associated with sustainability of program delivery. Using a mixed-methods design, quantitative evaluations of organizational functioning, barriers to implementation, burnout, and organizational readiness, as well as qualitative data utilizing the Consolidated Framework for Implementation Research (CFIR), were examined to evaluate program implementation. Participants were 184 health care providers from 46 clinics in Zambia. Successful implementation was associated with better community and leader support, and employee readiness and motivation. Quantitative assessments were not related to implementation and provided a limited picture of implementation outcomes. Results suggest that the qualitative data underlying the CFIR constructs provided a nuanced, contextual assessment of implementation, and dissemination outcomes. The CFIR may be valuable in informing the implementation of evidence-based interventions in other parts of Zambia.

Motivational Interviewing Training for HIV Care Physicians in Argentina: Uptake and Sustainability of an Effective Behavior Change Intervention

Motivational interviewing (MI) utilizes a patient-centered approach to address patient ambivalence about treatment and has been found to improve treatment ART adherence among patients living with HIV disengaged from care. This study examined MI training for clinicians, uptake, and sustainability over time. Clinics (n = 7) with N = 38 physicians were randomized to condition (MI, Enhanced Standard of Care). Physicians completed video- recorded patient consultations at baseline and 6, 12, and 18-month follow-up. MI condition physicians had greater relational and technical scores over time and were more likely to adhere to and sustain MI over time. Overall, physicians found the MI training highly acceptable and were able to sustain their skills. Results illustrate the feasibility of MI training, implementation, and sustainment over 18 months. Findings support previous research in Argentina in which trained physicians found MI useful with challenging patients. Broader implementation of MI among HIV care physicians in Argentina is merited.

Fertility intentions of women living with HIV and their male partners during the perinatal period in rural South Africa

Understanding the fertility intentions of people living with HIV can guide safer conception planning and prevention of mother-to-child transmission (PMTCT). Most research has addressed fertility intentions among women, rather than couples, at a single time point. This clinical trial of a PMTCT intervention in rural Mpumalanga province, South Africa, examined longitudinal fertility intentions among perinatal women living with HIV and their male partners. Study assessments and intervention and control sessions were conducted prenatally and postpartum. Longitudinal predictors of participants' (n = 360 men, n = 917 women) fertility intentions were similar between sexes. Younger age and male involvement in perinatal care were associated with reporting fertility intentions at both baseline and 12 months postpartum. Having an HIV-positive infant and discussing pregnancy plans with a healthcare provider by 12 months postpartum were associated with incident fertility intentions after reporting no plans for further children at baseline. Results highlight the important role of healthcare providers to educate men and women on issues surrounding conception, as well as the potential for incorporating PMTCT and safer conception education into HIV clinical services.

Maternal and infant antiretroviral therapy adherence among women living with HIV in rural South Africa: a cluster randomised trial of the role of male partner participation on adherence and PMTCT uptake

‘Mother-to-child transmission of HIV’ can occur during the period of pregnancy, childbirth, or breastfeeding. ‘Prevention of mother-to-child transmission of HIV’ (PMTCT) in Mpumalanga Province, South Africa, is especially vital as the prevalence of HIV is 28.2% in women aged 15–49. PMTCT interventions resulted in a drop of MTCT rates in Mpumalanga from ∼2% in 2015 to 1.3% in 2016. This randomised controlled trial in Mpumalanga examined the potential impact of a lay healthcare worker administered intervention, ‘Protect Your Family’, on maternal and infant adherence, and to assess the relative influence of male partner involvement on infant and maternal adherence. This cluster randomised controlled trial used a two-phase and two-condition (experimental or control) study design where participants (n = 1399) did assessments both during pregnancy and post-postpartum. Only women participated in Phase 1, and both female and male partners participated in Phase 2. Results indicated that male involvement was associated with self-reported maternal or infant antiretroviral therapy (ART) adherence, but the intervention was not associated with ART adherence. Self-reported adherence was associated with depression, age, and partner HIV status. The study results provide support for the involvement of men in the antenatal clinic setting during pregnancy. Results also support further research on the meaning and assessment of male involvement and clarification of the constructs underlying the concept in the sub-Saharan African context. Outcomes provide support for male involvement and treatment of depression as adjuncts to improve uptake of both maternal and infant medication as part of the PMTCT protocol.

Influence of Male Partners on HIV Disclosure Among South African Women in a Cluster Randomized PMTCT Intervention

Disclosure of HIV serostatus is beneficial for women, their partners, and their infants as it enables women to actively participate in preventative care (Hodgson et al. in PLoS ONE 9(11):e111421, 2014; Odiachi et al. in Reprod Health 15(1):36, 2018). Therefore, it is important that interventions addressing HIV prevention include elements that foster disclosure of HIV to partners. This study conducted in South Africa utilizes the "Protect Your Family" (PYF) behavioral intervention and compares Prevention of Mother to Child Transmission (PMTCT) among women participating in the program versus those in a control program. Within both groups, male partners were either present or not present for the intervention. The purpose of this study was to examine differential disclosure over time for individuals in the different conditions and partner involvement. A firth logistic regression revealed an interaction in the experimental condition with male partners participating (b = - 2.84, SE = 1.56, p = .012), in which female participants were less likely to disclose their HIV status over time. Findings from this study illustrate that additional efforts are needed to empower women to disclose their HIV status.

Heart Health and Behavior Change in HIV-Infected Individuals

Management of cardiovascular disease risk requires many lifestyle changes involving diet, smoking, and exercise. Individuals with arterial plaque are encouraged to adopt these changes to promote longevity through a variety of interventions. This study examined behavioral changes in response to the standard of care after detection of arterial plaque, specifically among HIV-infected cocaine users. 127 individuals (HIV - COC - n = 43, HIV + COC - n = 19, HIV + COC + n = 35, HIV - COC + n = 30) were followed after a standard of care intervention and assessed 1 and 2 years later on a variety of lifestyle (diet, exercise, smoking) and physiological (blood pressure, body mass index, number of arterial plaques) outcomes. Arterial plaque was found to increase over time (b = 0.003, SE = 0.002, p = .031), and a composite measure of cardiovascular disease risk did not change (b = - 0.004, SE = 0.01, p = .548). Following provision of a standard of care cardiovascular risk reduction intervention, important health behaviors related to CVD risk were resistant to change among both those HIV-infected and uninfected and among cocaine users and non-users.

The association of HIV and cocaine use to cigarette smoking in the context of depression and perceived stress

Mental well-being can contribute to cigarette smoking and negatively impact disease progression among people living with HIV (PLWH). This study examined potential associations between cocaine use (COC), depression, and HIV status in predicting cigarette smoking; hypothesizing that depression would be highest in cocaine users and predict cigarette smoking. An exploratory analysis including stress was also examined as a potential predictor of cigarette use. More than half of the sample (65%) endorsed smoking at some point in the past, and 52% endorsed being current smokers at the time of the study. Smokers were most likely to be cocaine users (87.1%), cocaine using PLWH (74.3%), or PLWH (36.6%). Neither HIV status (χ2(1) = 1.5, p = .221), perceived stress (χ2(1) = 0.75 p = .386), nor depressive symptomatology (χ2(1) = 1.2, p = .274) were related to smoking. Non-cocaine users were approximately 95.4% less likely to smoke than cocaine users, controlling for all other variables. Overall, cocaine use was the greatest predictor of cigarette smoking and quantity of cigarettes smoked. Perceived stress and depression were not associated with cigarette smoking in the sample. Future interventions targeting cigarette use should include a cocaine-related component to encourage smoking cessation among this high-risk group.

Cumulative Burden of Mental Health Factors and Engagement in HIV Care in Argentina

BACKGROUND

Cumulative burden of multiple mental health conditions may worsen physical health outcomes in vulnerable populations. Accordingly, identifying cumulative burdens of mental health conditions that may affect HIV treatment and care can guide public health strategies to reduce their impact on HIV-related health outcomes. This study examined the relationship between the cumulative burden of mental health conditions and factors associated with engagement in HIV care in Argentina.

METHOD

Data for this study was obtained at baseline from Conexiones y Opciones Positivas en la Argentina 2 (COPA2). Participants (N = 360) were cisgender patients living with HIV who were lost to care, recruited from seven clinics serving people living with HIV in four Argentine urban centers. Cumulative burden of mental health conditions (i.e., depressive symptoms, problematic substance use, unhealthy alcohol use, and psychotic symptoms) was assessed.

RESULTS

Every one-point increase in the number of mental health conditions present was associated with a decrement in patient-provider communication (b = - 0.22, p < .001), self-efficacy (b = - 0.13, p = .012), and motivation for adherence (b = - 0.11, p = .039).

CONCLUSION

This study found cumulative burden of depression, problematic substance use, unhealthy alcohol use, and psychotic symptoms to be negatively associated with factors related to engagement in HIV care. Results highlight the importance of identification and treatment of challenges to mental health, in order to ameliorate their influence on engagement in HIV care.

The contribution of syndemic conditions to cardiovascular disease risk

The syndemic conditions of low education, childhood maltreatment, depression, HIV, alcohol and cocaine use, and obesity have been established as independent risk factors for cardiovascular risk, but research examining the association between syndemic conditions and cardiovascular risk in high-risk populations is lacking. A total of N = 503 participants underwent an ultrasound of the carotid artery to assess for atherosclerotic plaque. Participants, HIV-infected (n = 202) and HIV-uninfected (n = 301) with and without a history of cocaine use, were a mean age of 36.13 years (SD = 9.51); 50% were male, and 62% were African-American. Each syndemic condition was associated with 8% greater odds of atherosclerotic plaque (OR = 1.08), 9% greater odds of systolic blood pressure (OR = 1.09), and 10% greater odds of diastolic blood pressure (OR = 1.10). Multilevel research, interventions, and public policy initiatives are needed to activate stakeholders at each level to maximize their impact at a community level among populations with high rates of syndemic conditions.

Suicidal Ideation Among Adults Re-engaging in HIV Care in Argentina

Argentina has one of the highest suicide rates in Latin America and the Caribbean. Though people living with HIV are at increased risk for suicidal behavior, little research on suicide risk has been conducted among HIV-positive people in this region. This study examined risk factors for suicidal ideation among HIV-infected adults (N = 360) re-engaging in care in Argentina. Overall, 21% of participants reported suicidal ideation in the past week. In adjusted logistic regression models, younger age, increased depressive symptomatology, and drug abuse were associated with suicidal ideation (p < 0.05); decreased motivation for adherence and fewer months since initiating antiretroviral therapy approached significance (p = 0.07). Suicidal ideation was common in this sample of HIV-positive patients in Argentina. Findings highlight the need for routine risk assessment and interventions integrated into the HIV care continuum, addressing depression, substance use, and suicidal behavior.

Development, implementation and dissemination: Couples and Parent-Child Communication Workshops in Zambia

Over a million people are living with HIV in Zambia, representing ∼13% of the country's population. To increase HIV prevention communication, a community-based communication training program, the Parent-Child and Couples Communication Workshop, was developed from pilot data and culturally tailored for dissemination in Zambia. Workshop trainees (N = 195) were 18 years of age or more and community educators and counselors in the Copperbelt and Southern Provinces of Zambia, e.g., peer educators, lay counselors, teachers, nurses, mentors and program officers, workshops (N = 16) were conducted. Satisfaction with the workshops, readiness to conduct a workshop and implementation were assessed. Overall, readiness to conduct workshops following training and satisfaction with the workshop was similarly high across Provinces. Following the initial training, more than half of workshop trainees conducted workshops in their own communities. Zambian community members were receptive to learning techniques to disseminate communication strategies that could prevent HIV transmission. The use of culturally appropriate strategies and a training of trainers approach for communication and prevention may have enhanced workshop dissemination in Zambian communities. Future research should explore the use of culturally congruent HIV prevention initiatives in the Zambian context.

HIV Prevention among Zambian Itinerant Workers: Challenges and Solutions

Mobility and alcohol abuse increase vulnerability to HIV among itinerants in Zambia. Itinerants face unique challenges to accessing HIV counselling, testing, and treatment. Zambian districts (Chingola, Mazabuka, Mufulira) were selected, and focus group discussions (FGDs = 12; n= 72) and key informant interviews (n = 71) were held. HIV risk and strategies to address barriers and facilitators of condom use, voluntary counselling and testing (VCT) and HIV-treatment were explored. Mobility increased sexual networks. Local bars, lodges, and truck stops were locations for sexual solicitation. Cheap lodgings were hot spots for HIV risk behavior. Difficulty accessing condoms and HIV treatment due to transience placed itinerants at elevated risk. Lack of clinics in rural areas further exacerbated itinerant risk. Initiatives to reduce these risks included implementation of border-clinics and employer-driven medical support for itinerants. Uptake of HIV prevention tools, health-education initiatives supporting itinerants, as well as health-care initiatives tailored to itinerant needs, are needed.

Maternal Factors Associated With Infant Neurodevelopment in HIV-Exposed Uninfected Infants

Background

This study evaluated maternal factors associated with infant neurodevelopmental outcomes among HIV-exposed uninfected (HEU) infants in rural South Africa. This study followed pregnant women living with HIV pre- and postpartum and evaluated sociodemographic factors, use of antiretrovirals (ARVs), and mental health factors as predictors of HEU infant developmental outcomes (cognitive, receptive, and expressive communication, fine and gross motor skills).

Methods

Participants were 80 mother–infant dyads. Mothers were assessed during pregnancy, and HEU infant development was assessed at a mean (SD) of 13.36 (1.89) months of age.

Results

Women were an average (SD) of 28.9 (5.2) years of age, and infants were on average 13.4 (1.9) months old. An analysis of covariance indicated that infants whose mothers had ARV detected in dry blood spots at 32 weeks of pregnancy had lower functioning scores in the cognitive domain than those with undetected ARV (n = 14; M, 15.3 vs 17.2; P = .048). Antenatal physical intimate partner violence was also associated with delayed cognitive functioning (F (1, 74), 4.96; P = .029).

Conclusions

This study found risks for delayed infant cognitive development to be associated with the use of ARV during pregnancy and intimate partner violence, although findings merit replication due to the low sample size. Given the growing number of HEU infants, the necessity to better understand the potential toxicity of ARV exposure in utero is apparent. Similarly, the need for preventing intimate partner violence and screening for, and managing, developmental delays among these infants is increasing.

Sexual risk behavior among HIV-infected women in South Africa at 12-months postpartum

The postnatal period is a time of increased susceptibility to HIV infection and superinfection for postpartum women, sexual partners, and infants. This study examined the effect of a prevention to mother-to-child transmission of HIV intervention compared to standard care, and factors associated with unprotected last sex and inconsistent condom use at 12-months postpartum. Participants were N = 1399 HIV-infected women 6-30 weeks pregnant (M = 18 weeks (SD = 5.75)) assessed during pregnancy and 12-months postpartum. Women were aged an average of 28 (SD = 5.82); 48% reported 10-11 years of education. Older age (adjusted odds ratio [AOR] = 1.00) and being employed (AOR = 1.51) were associated with greater odds of unprotected sex at 12-month postpartum. Disclosure of HIV status (AOR = 0.64) and greater male involvement during pregnancy (AOR = 0.92) were associated with lower odds of unprotected sex at 12-month postpartum. HIV negative or unknown partner status (AOR = 0.45) and greater depressive symptoms (AOR = 0.97) were associated with lower odds of inconsistent condom use at 12-months postpartum. The intervention was not associated with reduced sexual risk behavior. Future studies should address male involvement and consider measurement of culturally tailored male involvement constructs for men South Africa. Perinatal women may require support for sexual communication and gender equity to reduce sexual risk.

Impact of male partner involvement on mother-to-child transmission of HIV and HIV-free survival among HIV-exposed infants in rural South Africa: Results from a two phase randomised controlled trial

Background

The Sub-Saharan Africa region still remains the epicentre of the global HIV/AIDS epidemic. With regards to new paediatric HIV infections, almost 90% of new HIV infections are among children (aged 0–14 years), largely through mother to child transmission. Male Partner Involvement in Prevention of Mother to Child Transmission programmes is now strongly advocated as being key in improving infant outcomes. This study describes the role of Male Partner Involvement on infant HIV infection and mortality survival in the first year among HIV-exposed infants born from HIV positive mothers.

Methods

This study was a two-phase, two condition (intervention or control) longitudinal study as part of a clinic-randomized Prevention of Mother to Child Transmission controlled trial. For Phase 1, female participants were recruited without their male partners. In Phase 2, both female and male participants were enrolled in the study as couples in order to encourage active Male Partner Involvement during pregnancy. Participants had two assessments prenatally (8–24 weeks and 32 weeks) and three assessments postnatally (6 weeks, 6 months, and 12 months)

Results

About 1424 women were eligible for recruitment into the study and 18 eligible women declined to participate. All women had a partner; 54% were unmarried, 26% were cohabiting, and 20% were married. Just over half (55%) of the women had been diagnosed with HIV during the current pregnancy. Phase 1 had significantly more HIV-infected infants than Phase 2 at 12-months postpartum (aOR = 4.55 [1.38, 15.07]). Increased depressive symptoms were associated with infant HIV infection at 12-months (aOR = 1.06 [1.01, 1.10]). Phase 1 also had a significantly greater proportion of dead and HIV-infected infants than Phase 2 at 12-months (aOR = 1.98 [1.33, 2.94]).

Conclusion

Male partner involvement in antenatal care is critical in ensuring infant survival and HIV infection among children born to HIV-positive mothers. This study highlights the high risk of ante-and-post natal depression and underscores the need of screening for depression during pregnancy.

Trial registration

ClinicalTrials.Gov; Trial Number NCT02085356.

Increasing acceptability and uptake of voluntary male medical circumcision in Zambia: implementing and disseminating an evidence-based intervention

Voluntary medical male circumcision (VMMC) uptake in Africa could prevent 3.4 million HIV infections across a 10 year span. In Zambia, however, ~80 per cent of uncircumcised men report no interest in undergoing VMMC. The Spear & Shield (S&S) intervention has been shown to be more effective than control or observation of only conditions at increasing the number of VMMCs. This study identified predictors of S&S implementation success or failure to create an "early warning" system to enable remedial action during implementation. Participants were n = 48 staff members from 12 community health facilities conducting the S&S program in Lusaka Province, Zambia. Quantitative assessments included demographics, provider attitudes, barriers to research uptake, staff burnout, and organizational readiness. Qualitative interviews were also conducted and quantified for analysis using the Consolidated Framework for Implementation Research (CFIR). Two-thirds (66%) of staff were women with a mean age of 37.67 years (SD = 7.51). Quantitatively, staff performance (p = .033) and decreased levels of staff burnout (p = .025) were associated with S&S implementation success. Qualitatively, constructs such as improved planning, executing, and self-reflection and evaluation were associated with S&S implementation success (p = .005). Identifying these factors facilitated remedial action across health facilities. This study illustrates the utility of the CFIR to guide program decision making in VMMC implementation in the Zambian context. Early identification of challenges to implementation may enable remedial action to enhance the likelihood of program sustainability. Effective monitoring strategies for HIV prevention interventions may thus enhance dissemination, implementation, and sustainability goals to bridge research and practice.

Behavioral Medicine: a retro/prospective view of the field

The year 2017 was the 40th anniversary of the convening of the Yale Conference on Behavioral Medicine (Schwartz and Weiss, 1977). In honor of this defining moment in the history of the birthing of behavioral medicine as a formal integrative field of biobehavioral theories, research and applications, we were invited by the editors to take a retrospective and prospective look at the field. Recognizing that much has been written about this history over the years, we decided to write about the "back-channel," presenting never-before shared events associated with the birthing and evolution of the field in a way that would be fun to write and read. In the process we look back at the evolving definitions of behavioral medicine in light of contemporary advances and controversies in science. Our review includes a discussion of some of the present challenges/opportunities, and then considers the future with some "outside the box" possibilities. We outline some of the enormous advances which have taken place in technology since the 1970s and consider how such technologies can be transformative in redefining our field.

The effect of male involvement and a prevention of mother-to-child transmission (PMTCT) intervention on depressive symptoms in perinatal HIV-infected rural South African women

This study investigated perinatal depressive symptoms among HIV-infected women enrolled in a cluster-randomized, controlled trial in South Africa. Women (n = 1370) attending 12 community health centers were consecutively enrolled in a two-phase (phase 1 = without a male partner, phase 2 = with a male partner) and two-condition (experimental or control) prevention of mother-to-child transmission (PMTCT) intervention. Women were enrolled at 8-24 weeks pregnant and followed postpartum at 6 weeks and 6 and 12 months (retention rate = 69.8%). Antenatally, 45.4% of women were above the 12-point Edinburgh Postnatal Depression Scale (EPDS) cutoff, 30.2% were above the cutoff at 6 weeks, and 34.2% and 36.9% at 6 months and 12 months postpartum, respectively. In multilevel regression analyses, depressive symptoms decreased over time among women in phase 2 participating in the intervention condition, but neither condition nor phase alone was associated with a decrease in depression. Greater HIV stigma, increased psychological intimate partner violence, less male involvement, lower education, and non-adherence during pregnancy were associated with increased depressive symptoms over the perinatal period. Results indicated that women participating had high levels of depressive symptoms (> 40% prenatally and > 30% postnatally), and the combination of the multi-session PMTCT intervention plus male partner participation contributed to a reduction in depressive symptoms. Results suggest that interventions targeting the reduction of depressive symptoms in perinatal HIV-positive women by increasing male involvement and decreasing HIV stigma and intimate partner violence are needed to reduce depression in this vulnerable population.

Adolescent and young adult couples' views of intravaginal practices: a qualitative analysis of a pilot study

Purpose

In this study, we evaluated the risk behaviors that are drivers of the HIV epidemic among adolescent girls and young women in Zambia using a focus group research technique.

Subjects and methods

Eighteen adolescent couples (n=18 females and 18 males) aged 16–24 participated in six focus groups discussions (3 per gender) convened at three health facilities in Lusaka, Zambia. Focus group moderators utilized a set of open-ended questions to guide the 60-minute sessions. The focus group audio recordings were transcribed, coded, and analyzed using qualitative content analysis in Nvivo 11.

Results

Three themes and four subthemes were identified relating to adolescent and young adult couples’ knowledge, views, and male partner attitudes toward intravaginal practices (IVPs). The first theme, knowledge and rationale for IVPs, consisted of the subthemes relating to why adolescents and young adult couples engage in IVPs and assessed their knowledge of health risks associated with IVPs. The second theme, attitudes toward IVPs, consisted of the subtheme willingness to stop or support partner to discontinue IVP and practices toward IVP and strategies for changing. The third theme, strategies for changing IVPs, consisted of the subtheme raise awareness.

Conclusion

IVPs used for cleaning purposes were perceived as essential to enhancing hygiene, health, and sexual satisfaction for both girls and boys. However, couples expressed concern about the health effects of IVPs used for tightening and a desire for learning more about this practice as well as stopping it.

The Use of Efavirenz During Pregnancy is Associated with Suicidal Ideation in Postpartum Women in Rural South Africa

Efavirenz is used for the management of HIV infection during pregnancy in South Africa (SA), but it is contraindicated in patients with history of depression due to possible suicidal ideation. This study compared suicidal ideation 12-months postpartum among women receiving and not receiving efavirenz in rural SA, where high rates of depression have been identified. Antenatal psychological intimate partner violence (IPV; AOR = 1.04), depression (AOR = 1.06) and detection of efavirenz in dried blood spot at 32 weeks predicted suicidal ideation 12-months postnatally (AOR = 2.29), controlling for antenatal stigma and physical IPV. Findings support using alternative agents for the management of HIV during pregnancy.

Pre- and postnatal exposure to intimate partner violence among South African HIV-infected mothers and infant developmental functioning at 12 months of age

In rural South Africa, pregnant HIV-infected women report high rates of psychological (55%) and physical (20%) intimate partner violence (IPV). IPV increases the risk of infant developmental delays. Such delays may have negative socioemotional and cognitive outcomes throughout the lifespan. This paper assesses the relationship between IPV and infant development in rural South Africa. The present investigation was a cross-sectional add-on follow-up designed retrospectively. A randomly selected sub-sample of mothers from the main randomized controlled trial (n = 72) were asked to participate with their infants at 12 months of age; all women invited agreed to participate. Women were 18.35 ± 5.47 weeks pregnant; demographics, HIV disclosure status, and pre- and postnatal IPV measured via the Conflict Tactics Scale during pregnancy at baseline and 12 months post-partum were assessed. Infant HIV serostatus and developmental functioning at 12 months of age were assessed. Women were a mean age of 29 ± 2 years. One third had completed at least 12 years of education and had a monthly income of ~ US$76. At 12 months post-partum, 6% of infants tested HIV seropositive. Postnatal physical IPV was associated with delays in cognitive and receptive language development p < 0.05, but only in unadjusted analyses. This study identified an association between early IPV exposure and infant cognitive and receptive communication delays. Given the small sample size, findings support replication. Longitudinal studies are needed to confirm temporal order and identify appropriate timing for interventions in HIV-exposed infants.

Correlates of Suicidal Ideation During Pregnancy and Postpartum Among Women Living with HIV in Rural South Africa

In developing countries, up to 20% of maternal deaths during pregnancy are due to suicide, and being HIV-infected confers additional risk. This manuscript sought to identify perinatal correlates of suicidal ideation among women living with HIV (WLHIV) in rural South Africa. Pregnant WLHIV (N = 681) were recruited and re-assessed at 12-months postpartum. Mean age was 28.3 (SD = 5.7) years and 68% were below the poverty line. Prenatal suicidal ideation was 39%; suicidal ideation continued for 7% at 12 months, 13% experienced incident suicidal ideation, and for 19% suicidal ideation had stopped postnatally. Intimate partner violence (AOR = 1.17) and depression (AOR = 1.14) predicted sustained suicidal ideation. Increased income (AOR = 2.25) and greater stigma (AOR = 1.33) predicted incident suicidal ideation. Younger age (AOR = 0.94), disclosure of HIV status to partner (AOR = 0.60), and greater stigma (AOR = 1.24) predicted postnatal cessation of suicidal ideation. Perinatal care may provide windows of opportunity for identification and treatment of suicidal ideation.

A Bayesian Analysis of Prenatal Maternal Factors Predicting Nonadherence to Infant HIV Medication in South Africa

While efforts to prevent mother-to-child transmission of HIV been successful in some districts in South Africa, rates remain unacceptably high in others. This study utilized Bayesian logistic regression to examine maternal-level predictors of adherence to infant nevirapine prophylaxis, including intimate partner violence, maternal adherence, HIV serostatus disclosure reaction, recency of HIV diagnosis, and depression. Women (N = 303) were assessed during pregnancy and 6 weeks postpartum. Maternal adherence to antiretroviral therapy during pregnancy predicted an 80% reduction in the odds of infant nonadherence [OR 0.20, 95% posterior credible interval (.11, .38)], and maternal prenatal depression predicted an increase [OR 1.04, 95% PCI (1.01, 1.08)]. Results suggest that in rural South Africa, failure to provide medication to infants may arise from shared risk factors with maternal nonadherence. Intervening to increase maternal adherence and reduce depression may improve adherence to infant prophylaxis and ultimately reduce vertical transmission rates.

The role of social support in the association between childhood trauma and depression among HIV-infected and HIV-uninfected individuals

Childhood trauma (CT) - emotional, physical or sexual abuse, or emotional or physical neglect - has been associated with HIV infection and can lead to poor health outcomes and depression in adulthood. Though the impact of CT on depression may be decreased by social support, this may not be true of individuals living with HIV, due to the additive traumatic effects of both CT and acquisition of HIV. This study examined social support, depression, and CT among HIV-infected (n = 134) and HIV-uninfected (n = 306) men and women. Participants (N = 440) were assessed regarding sociodemographic characteristics, CT, depression, and social support. Participants were racially and ethnically diverse, 36 ± 9 years of age on average, and 44% had an income of less than USD$500 a month. Among HIV-uninfected individuals, social support explained the association between depression in persons with CT ( b = 0.082, bCI [0.044, 0.130]). Among HIV-infected individuals, after accounting for sociodemographic characteristics, social support did not explain the association between depression and CT due to lower levels of social support among HIV-infected individuals [95% CI: -0.006, 0.265]. The quality of social support may differ among HIV-infected persons due to decreased social support and smaller social networks among those living with HIV. Depressive symptoms among those living with HIV appear to be less influenced by social support, likely due to the additive effects of HIV infection combined with CT.

Physician-delivered motivational interviewing to improve adherence and retention in care among challenging HIV-infected patients in Argentina (COPA2): study protocol for a cluster randomized controlled trial

BACKGROUND

"Challenging" HIV-infected patients, those not retained in treatment, represent a critical focus for positive prevention, as linkage to care, early initiation of antiretroviral therapy, adherence and retention in treatment facilitate viral suppression, thus optimizing health and reducing HIV transmission. Argentina was one of the first Latin American countries to guarantee HIV prevention, diagnosis and comprehensive care services, including antiretroviral medication, which removed cost and access as barriers. Yet, dropout occurs at every stage of the HIV continuum. An estimated 110,000 individuals are HIV-infected in Argentina; of these, 70% have been diagnosed and 54% were linked to care. However, only 36% have achieved viral suppression and 31% of those diagnosed delayed entry to care. To achieve meaningful reductions in HIV infection at the community level, innovative strategies must be developed to re-engage patients. Motivational Interviewing (MI) is a patient-centered approach and has been used by therapists in Central and South America to enhance motivation and commitment in substance use and risk reduction. Our pilot feasibility study utilized culturally tailored MI in physicians to target patients not retained in treatment in public and private clinics in Buenos Aires, Argentina. Results demonstrated that a physician-based MI intervention was feasible and effective in enhanced and sustained patient adherence, viral suppression, and patient-physician communication and attitudes about treatment among these patients at 6 and 9 months post baseline.

METHODS/DESIGN

This clinical trial seeks to extend these findings in public and private clinics in four urban population centers in Argentina, in which clinics (n = 6 clinics, six MDs per clinic site) are randomized to experimental (physician MI Intervention) (n = 3) or control (physician Standard of Care) (n = 3) conditions in a 3:3 ratio. Using a cluster randomized clinical trial design, the study will test the effectiveness of a physician-based MI intervention to improve and sustain retention, adherence, persistence, and viral suppression among "challenging" patients (n = 420) over 24 months.

DISCUSSION

Results are anticipated to have significant public health implications for the implementation of MI to re-engage and retain patients in HIV treatment and care and improve viral suppression through high levels of medication adherence.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02846350 . Registered on 1 July 2016.

Sexual risk behaviour among HIV-infected women in the first twelve months after delivery in South Africa

This study aimed to assess sexual risk behaviour and its social correlates in HIV-infected women living in rural South Africa at six and twelve months post-partum. Participants were 699 HIV-positive women recruited prenatally by systematic sampling from twelve community health centres in Mpumalanga province, South Africa (mean age = 28.4 years, SD = 5.7; married =41.1%; serodiscordant or unknown partner status = 74.9%). They self-reported on their sexual activity six to twelve months after delivery; including use of condoms and partner involvement. Generalised linear mixed models were utilised to estimate unsafe sex outcomes from a prevention of mother to child transmission (PMTCT) intervention, socio-demographic factors, disclosure, and male involvement. About 20% of sexually active women in the past week had used condoms inconsistently at six and twelve months after delivery. Moreover, 16% and 18% of the women had not used a condom at last sex and 11% and 13% had unprotected sex with HIV-uninfected or unknown-status partners following delivery at six and twelve months, respectively. Higher inconsistent condom use was likely with lower male involvement. Promotion of condom use post-partum, as well as male involvement in sexual decisions, are important for safer sex post-partum by seropositive women.

Infant Development and Pre- and Post-partum Depression in Rural South African HIV-Infected Women

HIV-exposed infants born to depressed women may be at risk for adverse developmental outcomes. Half of HIV-infected women in rural South Africa (SA) may suffer from pregnancy-related depression. This pilot study examined the impact of depression in HIV-infected women in rural SA on infant development. Mother-infant dyads (N = 69) were recruited in rural SA. Demographics, HIV disclosure, depression, male involvement, and alcohol use at baseline (18.35 ± 5.47 weeks gestation) were assessed. Male involvement, depression, infant HIV serostatus and development were assessed 12 months postnatally. Half of the women (age = 29 ± 5) reported depression prenatally and one-third reported depression postnatally. In multivariable logistic regression, not cohabiting with their male partner, nondisclosure of HIV status, and postnatal depression predicted cognitive delay; decreased prenatal male involvement predicted delayed gross motor development (ps < 0.05). Assessing pregnancy-related depression among HIV-infected women and infant development and increasing male involvement may reduce negative developmental outcomes among HIV-exposed or infected infants.

Reproductive decision-making among postpartum HIV-infected women in rural South Africa

Despite pregnancy spacing recommendations to optimize health outcomes among mothers and neonates, unplanned pregnancy in sub-Saharan Africa is common among women living with human immunodeficiency virus (HIV) (WLHIV). This study examined factors associated with reproductive decision-making among WLHIV to inform pregnancy-planning interventions. WLHIV in rural South Africa (n = 165) were assessed at 12 months postpartum. The relative importance of factors associated with reproductive decision-making was estimated. Women were a mean of 28 years old (SD = 5.71). Risk of mother-to-child transmission (MTCT) of HIV (Mean = 0.43; SD = 0.33) had the greatest impact on decision-making, followed by partners' desires (M = 0.22; SD = 0.18), family preferences (M = 0.18; SD = 0.13), and community opinion (M = 0.17; SD = 0.13). MTCT was most important to women with greater HIV knowledge. However, WLHIV who had been diagnosed with HIV for a longer time placed more emphasis on partner preference and community opinion, and less importance on MTCT risk. Prevention of mother-to-child transmission (PMTCT) was less important to women experiencing intimate partner violence and those with depression. Findings highlight the need for tailored, focused interventions to support the unique circumstances of WLHIV and support the inclusion of families and/or partners in the counseling process. Results underscore the need for perinatal preconception counseling for women during routine HIV care.

Suicidality among nonadherent patients living with HIV in Buenos Aires, Argentina: prevalence and correlates

Of those in the general population hospitalized for suicidal ideation and suicide attempts in Argentina, many reattempt suicide and are readmitted. However, few studies in Argentina have examined suicidal ideation and suicide-related behaviors among people living with HIV (PLHIV) and none have examined these factors among nonadherent PLHIV, though the prevalence of suicidal ideation in this group may be higher than in the general population and also than in other groups of PLHIV. This study of PLHIV in Buenos Aires, Argentina, examined the correlates of suicidal ideation in nonadherent PLHIV. Nonadherent patients with HIV (N = 118) were recruited from two clinics providing outpatient healthcare services to PLHIV in Buenos Aires, Argentina. Participants completed assessments on demographic characteristics, depression and suicidality, stigma, and self-efficacy. Participants were HIV-infected men (51%) and women (49%) with a median age of 40 years (IQR = 11). About half had completed high school or more, two-thirds were employed, and had a mean monthly income of 4196.79 (SD = 3179.64) Argentine pesos (USD$221). Thirty-three (28% [95% CI 20.3, 37.3]) participants reported suicidal ideation in the past two weeks, and one-third (35.6% [27.1, 44.9]) reported lifetime suicidal ideation. In bivariate analyses, attending a public clinic, being female, younger, unemployed, and experiencing greater stigma and depression were associated with suicidal ideation. In multivariable logistic regression, stigma interacted with the number of years since HIV diagnosis to predict suicidal ideation. The impact of stigma on suicidal ideation decreased with time since HIV diagnosis, suggesting that suicidal ideation may arise following HIV diagnosis due to perception of HIV-related stigma. Interventions to reduce perceived stigma during the period following HIV diagnosis may reduce suicidal ideation in this population. Organizational initiatives that explore HIV stigma microagressions in the healthcare setting may be needed to optimize health outcomes.

Fertility intentions of prenatal and postpartum HIV-positive women in primary care in Mpumalanga province, South Africa: a longitudinal study

Introduction

This study aimed to assess fertility intentions (planning to have more children in the future) and associated factors among pregnant and postpartum HIV positive women in rural South Africa.

Methods

In a longitudinal study, as part of a prevention of mother to child transmission (PMTCT) intervention trial, 699 HIV positive prenatal women, were systematically recruited and followed up at 6 months and 12 months postpartum (retention rate = 59.5%).

Results

At baseline, 32.9% of the women indicated fertility intentions and at 12 months postnatal, 120 (28.0%) reported fertility intentions. In longitudinal analyses, which included time-invariant baseline characteristics predicting fertility intention over time, not having children, having a partner with unknown/HIV-negative status, and having disclosed their HIV status to their partner, were associated with fertility intentions. In a model with time-varying covariates, decreased family planning knowledge, talking to a provider about a future pregnancy, and increased male involvement were associated with fertility intentions.

Conclusion

Results support ongoing perinatal family planning and PMTCT education.

Prevalence and Factors Associated with Fixed-Dose Combination Antiretroviral Drugs Adherence among HIV-Positive Pregnant Women on Option B Treatment in Mpumalanga Province, South Africa

The possibility for all babies to be born and remain HIV-negative for the first year of life is achievable in South Africa. HIV-positive mothers' adherence to their antiretroviral medication is one of the crucial factors to achieve this target. Cross-sectional data were collected at 12 community health centres, over 12 months (2014-2015), from 673 HIV-positive women, less than 6 months pregnant, attending antenatal care, and on Option B treatment. Adherence measures included the Adults AIDS Clinical Trials Group (AACTG) four-day measure, as well as the Visual Analog Scale (VAS) seven-day measure. Bivariate analyses and multivariate logistic regressions are presented. 78.8% of respondents were adherent on AACTG, while 68.8% reported VAS adherence. Bivariate analyses for increased adherence show significant associations with older age, less/no alcohol usage, disclosure of HIV status, higher HIV knowledge, no desire to avoid ARV side effects, low stigma, and low depression. AACTG showed a negative association with intimate partner violence. Multivariable logistic regression on AACTG and VAS adherence rates resulted in unique contributions to increased adherence of older age, less/no alcohol usage, higher HIV knowledge, lack of depression, and non-disclosure. Programs targeting closer side effect monitoring, HIV disclosure, pre-natal depression, alcohol intake, and HIV knowledge need consideration.

HIV Knowledge and Risk among Zambian Adolescent and Younger Adolescent Girls: Challenges and Solutions

In sub-Saharan Africa, young women are at the highest risk of HIV infection. Comprehensive sexuality education (CSE) and open parent-child communication about sex have been shown mitigate risky sexual practices associated with HIV. This study aimed to identify sources of HIV prevention knowledge among young women aged 10-14 years and community-based strategies to enhance HIV prevention in Zambia. Focus group discussions were conducted with 114 young women in Zambian provinces with the highest rates (~20%) of HIV. Discussions were recorded, transcribed and coded, and addressed perceived HIV risk, knowledge and access to information. Participants reported that limited school-based sexuality education reduced the potential to gain HIV prevention knowledge, and that cultural and traditional practices promoted negative attitudes regarding condom use. Parent-child communication about sex was perceived to be limited; parents were described as feeling it improper to discuss sex with their children. Initiatives to increase comprehensive sexuality education and stimulate parental communication about sexual behavior were suggested by participants. Culturally tailored programmes aiming to increase parent-child communication appear warranted. Community-based strategies aimed at enhancing protective sexual behaviour among those most at risk are essential.

A cluster randomized controlled trial of lay health worker support for prevention of mother to child transmission of HIV (PMTCT) in South Africa

BACKGROUND

We evaluate the impact of clinic-based PMTCT community support by trained lay health workers in addition to standard clinical care on PMTCT infant outcomes.

METHODS

In a cluster randomized controlled trial, twelve community health centers (CHCs) in Mpumalanga Province, South Africa, were randomized to have pregnant women living with HIV receive either: a standard care (SC) condition plus time-equivalent attention-control on disease prevention (SC; 6 CHCs; n  = 357), or an enhanced intervention (EI) condition of SC PMTCT plus the "Protect Your Family" intervention (EI; 6 CHCs; n  = 342). HIV-infected pregnant women in the SC attended four antenatal and two postnatal video sessions and those in the EI, four antenatal and two postnatal PMTCT plus "Protect Your Family" sessions led by trained lay health workers. Maternal PMTCT and HIV knowledge were assessed. Infant HIV status at 6 weeks postnatal was drawn from clinic PCR records; at 12 months, HIV status was assessed by study administered DNA PCR. Maternal adherence was assessed by dried blood spot at 32 weeks, and infant adherence was assessed by maternal report at 6 weeks. The impact of the EI was ascertained on primary outcomes (infant HIV status at 6 weeks and 12 months and ART adherence for mothers and infants), and secondary outcomes (HIV and PMTCT knowledge and HIV transmission related behaviours). A series of logistic regression and latent growth curve models were developed to test the impact of the intervention on study outcomes.

RESULTS

In all, 699 women living with HIV were recruited during pregnancy (8-24 weeks), and assessments were completed at baseline, at 32 weeks pregnant (61.7%), and at 6 weeks (47.6%), 6 months (50.6%) and 12 months (59.5%) postnatally. Infants were tested for HIV at 6 weeks and 12 months, 73.5% living infants were tested at 6 weeks and 56.7% at 12 months. There were no significant differences between SC and EI on infant HIV status at 6 weeks and at 12 months, and no differences in maternal adherence at 32 weeks, reported infant adherence at 6 weeks, or PMTCT and HIV knowledge by study condition over time.

CONCLUSION

The enhanced intervention administered by trained lay health workers did not have any salutary impact on HIV infant status, ART adherence, HIV and PMTCT knowledge. Trial registration clinicaltrials.gov: number NCT02085356.

The Achilles' heel of prevention to mother-to-child transmission of HIV: Protocol implementation, uptake, and sustainability

The Joint United Nations Programme on HIV and AIDS proposed to reduce the vertical transmission of HIV from ∼72,200 to ∼8300 newly infected children by 2015 in South Africa (SA). However, cultural, infrastructural, and socio-economic barriers hinder the implementation of the prevention of mother-to-child transmission (PMTCT) protocol, and research on potential solutions to address these barriers in rural areas is particularly limited. This study sought to identify challenges and solutions to the implementation, uptake, and sustainability of the PMTCT protocol in rural SA. Forty-eight qualitative interviews, 12 focus groups discussions (n = 75), and one two-day workshop (n = 32 participants) were conducted with district directors, clinic leaders, staff, and patients from 12 rural clinics. The delivery and uptake of the PMTCT protocol was evaluated using the Consolidated Framework for Implementation Research (CFIR); 15 themes associated with challenges and solutions emerged. Intervention characteristics themes included PMTCT training and HIV serostatus disclosure. Outer-setting themes included facility space, health record management, and staff shortage; inner-setting themes included supply use and availability, staff-patient relationship, and transportation and scheduling. Themes related to characteristics of individuals included staff relationships, initial antenatal care visit, adherence, and culture and stigma. Implementation process themes included patient education, test results delivery, and male involvement. Significant gaps in care were identified in rural areas. Information obtained from participants using the CFIR framework provided valuable insights into solutions to barriers to PMTCT implementation. Continuously assessing and correcting PMTCT protocol implementation, uptake and sustainability appear merited to maximize HIV prevention.

Subclinical Atherosclerosis Among Young and Middle-Aged Adults Using Carotid Intima-Media Thickness Measurements

OBJECTIVES

The presence of atherosclerotic plaque in the carotid arteries is a strong predictor of cardiovascular disease (CVD). Research and data on CVD risk have been derived primarily from individuals aged 55 years or older, and assessment of CVD risk among young and middle-aged adults seldom has been studied. The use of ultrasonography to measure carotid intima-media thickness (IMT) and carotid plaque appears to have utility to detect subclinical atherosclerosis in asymptomatic adults. This study evaluated the presence of carotid plaque using ultrasonography among healthy young and middle-aged adults.

METHODS

Participants were men and women recruited in Miami, Florida, and were 18 to 50 years old with no history of CVD. Participants underwent a general physical examination and carotid artery ultrasonography to evaluate carotid IMT and carotid plaque.

RESULTS

From a total of 173 participants with a mean age of 34 years (standard deviation 8.9), 21.0% (95% confidence interval [CI] 15.0-27.2) were identified as having carotid plaque. IMT values ranged from 0.49 to 1.03 mm, with a mean value of 0.70 mm (standard deviation 0.09). In multivariable logistic regression older age (adjusted odds ratio [AOR] 1.08, 95% CI 1.01-1.16, P = 0.024) and cigarette smoking (AOR 2.67, 95% CI 1.02-7.00, P = 0.045) were associated with plaque, after controlling for IMT (AOR 2.55, 95% CI 1.40-4.65, P = 0.002).

CONCLUSIONS

Traditional CVD risk factors such as those evaluated in this study may fail to provide adequate predictive value of carotid atherosclerosis in younger populations with no history of CVD, because the majority of traditional risk factors identified in previous research were not associated with carotid plaque in this young sample. Further research assessing nontraditional risk factors among asymptomatic individuals is required, and the evaluation of IMT as an intervention tool to detect CVD risk in these asymptomatic populations is warranted.

Let us fight and support one another: adolescent girls and young women on contributors and solutions to HIV risk in Zambia

In Zambia, adolescent girls and young women (AGYW) are disproportionately affected by human immunodeficiency virus (HIV), social, cultural and economic factors making them particularly vulnerable. This study was designed to understand the context in which AGYW are at risk and to identify perceived drivers of the epidemic and potential strategies to reduce HIV risk. Focus group discussions were conducted with AGYW in Zambian districts with the highest HIV prevalence from February through August 2016. The focus group guide addressed HIV risk factors and strategies for HIV prevention in AGYW. Focus group discussions were recorded, translated and transcribed, themes identified and responses coded. Results suggest that gender inequality undermined potentially protective factors against HIV among AGYW. Poverty and stigmatization were major barriers to accessing available HIV prevention services as well as primary risk factors for HIV infection. Sponsorship to support AGYW school attendance, programs for boys and girls to foster gender equality and financial assistance from the government of Zambia to support AGYW most in need were proposed as strategies to reduce HIV risk. Results highlight the utility of using community-based research to guide potential interventions for the affected population. Future research should explore the use of multilevel interventions to combat HIV among AGYW.

Adolescent girls and young women living with HIV: preconception counseling strategies

Background

Rates of pregnancy among women living with HIV are similar to those in the general population. Unintended pregnancies are also common, and among adolescents and young women perinatally infected (PHIV+) or behaviorally infected (BHIV+) with HIV, planning for both conception and contraception is an important element of HIV care that may be neglected. This pilot study examined the influence of intervention strategies targeting fertility planning, safer conception practices and patient-provider communication. It was hypothesized that preconception counseling interventions would enhance reproductive knowledge, planning and practices, as well as stimulate discussion with providers regarding conception.

Methods

Adolescent girls and young women (N=34) perinatally (n=21) or behaviorally (n=13) infected with HIV, aged 16–29 years, were recruited from urban South Florida, and completed measures of reproductive knowledge, sexual practices and fertility intentions. Participants were randomized to condition, ie, video presentation plus Motivational Interviewing (MI), MI only, control.

Results

The average age of women was 22 years (SD =3.27), and the majority of them were African American. Levels of depression were higher among BHIV+ compared to PHIV+ at baseline and 6 months. Pregnancy knowledge (pregnancy, safe conception and pregnancy planning) and the proportion of those engaging in birth control planning (condom use, long-term birth control, patient-provider discussions on preventing pregnancy and fertility desires) were similar between conditions at post-intervention and 6 months. Bayes factors indicated that the data were insensitive with regard to differences between conditions, limiting support for both the null and alternative hypotheses.

Conclusion

The impact of interventions used in this study to stimulate pregnancy planning was inconclusive. Results suggest that pregnancy planning interventions may require greater intensity to influence sexual behavior in this population. Despite adequate reproductive knowledge, HIV-infected adolescent girls and young women may fail to engage in planning behavior.

Influencing the importance of health, partners, and hygiene among Zambian women

Intravaginal practices (IVPs) are common in Zambia and are usually practiced for hygiene, partner pleasure, and health. IVPs are associated with HIV acquisition, changes in the vaginal flora, and bacterial vaginosis (BV), making it important to understand the decision-making process behind IVP engagement. The Women's and Sexual Health (WASH) intervention decreased IVP engagement among HIV-infected Zambian women, though change in reasons for engagement has not been assessed. We used conjoint analysis (CA) to quantify the decision-making process of IVP engagement and evaluated how the WASH intervention impacted these factors. Participants were N = 84 women (37 ± 8 years old) randomized to WASH (n = 46) or standard of care plus (SOC+; n = 38) who completed demographic measures and a CA questionnaire at baseline, six months, and 12 months to quantify the importance placed on hygiene, partner pleasure, and health. The importance placed on health increased from baseline to six months (15.5 versus 25.1; p < 0.001) and from baseline to 12 months (15.5 versus 50.5; p < 0.001), and was higher in SOC+ at six months (19.9 versus 30.3; p = 0.003). Hygiene importance decreased from baseline (63.6) to six months (50.3), and from baseline to 12 months (26.1), and was higher in the experimental arm at six months (56.1) compared to SOC+ (44.6; p = 0.029). Importance placed on partner pleasure did not change over time in either group. Findings suggest that both groups exhibited an increase in the importance placed on health and a decrease on hygiene importance for IVP engagement, suggesting that SOC+ may be sufficient to promote attitude changes that may facilitate IVP discontinuation and may prove to be more cost effective by using fewer monetary resources. Findings highlight the potential of interventions to influence attitudes toward IVPs and provide novel avenues for research to improve the design and conduct of interventions aimed at reducing IVPs among Zambian women and contribute to HIV prevention efforts.

Self-Report and Dry Blood Spot Measurement of Antiretroviral Medications as Markers of Adherence in Pregnant Women in Rural South Africa

Antiretroviral (ARV) adherence is essential to prevent mother-to-child transmission of HIV. This study compared self-reported adherence versus ARV detection in dried blood spots (DBS) among N = 392 HIV-infected pregnant women in South Africa (SA). Women completed two self-reported adherence measures [visual analog scale (VAS), AIDS Clinical Trials Group Adherence (ACTG)]. Adherence was 89% (VAS), 80% (ACTG), and 74% (DBS). Self-report measures marginally agreed with DBS (VAS: Kappa = 0.101, Area under the ROC curve (AUROC) = 0.543; ACTG: Kappa  = 0.081, AUROC = 0.538). Self-reported adherence was overestimated and agreement with DBS was poor. Validation of self-reported ARV adherence among pregnant HIV+ women in SA is needed.