51
|
Phuphanich M, Rattanamahattana M, Avihingsanon A, Chetchotisakd P, Putcharoen O, Gandhi M, Sohn AH, Imrie J, Phanuphak P, Kerr SJ. A qualitative assessment of barriers and facilitators to antiretroviral adherence in Thai patients. J Virus Erad 2016. [DOI: 10.1016/s2055-6640(20)30692-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
52
|
Phuphanich M, Rattanamahattana M, Avihingsanon A, Chetchotisakd P, Putcharoen O, Gandhi M, Sohn AH, Imrie J, Phanuphak P, Kerr SJ. A qualitative assessment of barriers and facilitators to antiretroviral adherence in Thai patients. J Virus Erad 2016; 2:22-7. [PMID: 27482431 PMCID: PMC4946691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Excellent adherence to combination antiretroviral therapy can suppress HIV replication and produce life expectancies nearing those of individuals without HIV infection. This qualitative study sought to identify the barriers and facilitators to good antiretroviral medication adherence in Thai patients living with HIV. METHODS Semi-structured interviews were conducted with a convenience sample (n=21) of patients attending routine clinic visits at Srinagarind Hospital in Khon Kaen, or HIV-NAT, the Thai Red Cross AIDS Research Centre in Bangkok. RESULTS Median informant age was 43 years (range 27-60 years) and 43% were female. We identified key facilitators and barriers to adherence among HIV-infected Thai patients along three major themes (patient-related, health system-related and medication-related). Stigma was a primary concern for most informants, operating throughout Thai society to induce feelings of shame for Thai people living with HIV. Determination to stay healthy and incorporate taking cART into their daily routine were key components of good adherence. Supportive and trusting relationships, particularly with the clinic team, empowered patients to maintain good medication adherence. CONCLUSIONS Changing public perceptions about HIV, and training of HIV clinic staff on the importance of trusting and supportive provider-patient relationships in promoting good health outcomes, will help Thailand achieve its aim of having zero new HIV infections, zero discrimination and zero AIDS-related deaths by 2030.
Collapse
Affiliation(s)
| | | | - Anchalee Avihingsanon
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Opass Putcharoen
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Monica Gandhi
- School of Medicine, University of California, San Francisco, USA
| | - Annette H Sohn
- TREAT Asia/amfAR –The Foundation for AIDS Research, Bangkok, Thailand
| | - John Imrie
- Centre for Sexual Health and HIV Research, Department of Infection and Population Health, University College London, UK,Faculty of Arts and Social Sciences, University of New South Wales, Sydney, Australia
| | - Praphan Phanuphak
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Stephen J Kerr
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand,Kirby Institute, University of New South Wales, Sydney, Australia,Amsterdam Institute of Global Health and Development (AIGHD), the Netherlands,Corresponding author: Stephen J Kerr, HIV-NAT, Thai Red Cross AIDS Research Centre, 104 Ratchadamri Road, Bangkok10330, Thailand
| |
Collapse
|
53
|
Contemporary issues on the epidemiology and antiretroviral adherence of HIV-infected adolescents in sub-Saharan Africa: a narrative review. J Int AIDS Soc 2015; 18:20049. [PMID: 26385853 PMCID: PMC4575412 DOI: 10.7448/ias.18.1.20049] [Citation(s) in RCA: 155] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 07/10/2015] [Accepted: 08/12/2015] [Indexed: 12/25/2022] Open
Abstract
Introduction Adolescents are a unique and sometimes neglected group in the planning of healthcare services. This is the case in many parts of sub-Saharan Africa, where more than eight out of ten of the world's HIV-infected adolescents live. Although the last decade has seen a reduction in AIDS-related mortality worldwide, largely due to improved access to effective antiretroviral therapy (ART), AIDS remains a significant contributor to adolescent mortality in sub-Saharan Africa. Although inadequate access to ART in parts of the subcontinent may be implicated, research among youth with HIV elsewhere in the world suggests that suboptimal adherence to ART may play a significant role. In this article, we summarize the epidemiology of HIV among sub-Saharan African adolescents and review their adherence to ART, emphasizing the unique challenges and factors associated with adherence behaviour. Methods We conducted a comprehensive search of online databases for articles, relevant abstracts, and conference reports from meetings held between 2010 and 2014. Our search terms included “adherence,” “compliance,” “antiretroviral use” and “antiretroviral adherence,” in combination with “adolescents,” “youth,” “HIV,” “Africa,” “interventions” and the MeSH term “Africa South of the Sahara.” Of 19,537 articles and abstracts identified, 215 met inclusion criteria, and 148 were reviewed. Discussion Adolescents comprise a substantial portion of the population in many sub-Saharan African countries. They are at particular risk of HIV and may experience worse outcomes. Although demonstrated to have unique challenges, there is a dearth of comprehensive health services for adolescents, especially for those with HIV in sub-Saharan Africa. ART adherence is poorer among older adolescents than other age groups, and psychosocial, socio-economic, individual, and treatment-related factors influence adherence behaviour among adolescents in this region. With the exception of a few examples based on affective, cognitive, and behavioural strategies, most adherence interventions have been targeted at adults with HIV. Conclusions Although higher levels of ART adherence have been reported in sub-Saharan Africa than in other well-resourced settings, adolescents in the region may have poorer adherence patterns. There is substantial need for interventions to improve adherence in this unique population.
Collapse
|
54
|
Chan BT, Tsai AC, Siedner MJ. HIV Treatment Scale-Up and HIV-Related Stigma in Sub-Saharan Africa: A Longitudinal Cross-Country Analysis. Am J Public Health 2015; 105:1581-7. [PMID: 26066939 DOI: 10.2105/ajph.2015.302716] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa. METHODS We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable. RESULTS Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = -0.226; P = .007; 95% confidence interval [CI] = -0.383, -0.070) and men (b = -0.281; P = .009; 95% CI = -0.480, -0.082) in the general population reporting HIV-related stigma. CONCLUSIONS An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population.
Collapse
Affiliation(s)
- Brian T Chan
- Brian T. Chan, Alexander C. Tsai, and Mark J. Siedner are with Harvard Medical School, Boston, MA. Brian T. Chan is also with the Brigham and Women's Hospital, Boston. Alexander C. Tsai and Mark J. Siedner are also with Massachusetts General Hospital, Boston
| | - Alexander C Tsai
- Brian T. Chan, Alexander C. Tsai, and Mark J. Siedner are with Harvard Medical School, Boston, MA. Brian T. Chan is also with the Brigham and Women's Hospital, Boston. Alexander C. Tsai and Mark J. Siedner are also with Massachusetts General Hospital, Boston
| | - Mark J Siedner
- Brian T. Chan, Alexander C. Tsai, and Mark J. Siedner are with Harvard Medical School, Boston, MA. Brian T. Chan is also with the Brigham and Women's Hospital, Boston. Alexander C. Tsai and Mark J. Siedner are also with Massachusetts General Hospital, Boston
| |
Collapse
|
55
|
Associations of stigma with negative health outcomes for people living with HIV in the Gambia: implications for key populations. J Acquir Immune Defic Syndr 2015; 68 Suppl 2:S146-53. [PMID: 25723979 DOI: 10.1097/qai.0000000000000453] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The HIV epidemic in the Gambia is concentrated among stigmatized key populations. This study explores the relationship between 3 types of HIV-related stigma and 3 health outcomes among people living with HIV (PLHIV) in the Gambia. METHODS Three hundred seventeen PLHIV from PLHIV support groups in the Gambia were surveyed using the PLHIV Stigma Index. RESULTS Enacted stigma in health care settings was significantly associated with avoiding or delaying seeking care [adjusted odds ratio (aOR) = 3.03, 95% confidence interval (CI) = 1.24 to 7.89]; enacted stigma in the household or community (aOR = 1.21, 95% CI = 0.98 to 1.49) and internal stigma (aOR = 1.47, 95% CI = 0.96 to 2.22) were marginally associated. Enacted stigma in health care settings was significantly associated with non-use of antiretroviral therapy (aOR = 0.52, 95% CI = 0.31 to 0.88), whereas internal stigma and enacted stigma in the household or community were not. Enacted stigma in the household or community (aOR = 0.75, 95% CI = 0.64 to 0.87) and internal stigma (aOR = 0.69, 95% CI = 0.50 to 0.93) were significantly associated with poorer self-reported health status, whereas enacted stigma in health care settings was not. CONCLUSIONS PLHIV in the Gambia face stigma regardless of identity as members of key populations, who may face dual stigma. Stigma mitigation represents a potentially important component of a comprehensive package of services to improve the HIV care continuum in the Gambia. Targeted interventions that address stigma with health care workers could facilitate antiretroviral therapy use and timely care seeking for PLHIV. Interventions to address internal stigma and enacted stigma in the household and community may yield additional dividends for the overall health of PLHIV. Examining only 1 domain of stigma may not be sufficient to understand the effect of stigma on a specific health outcome.
Collapse
|
56
|
Pantelic M, Shenderovich Y, Cluver L, Boyes M. Predictors of internalised HIV-related stigma: a systematic review of studies in sub-Saharan Africa. Health Psychol Rev 2015; 9:469-90. [DOI: 10.1080/17437199.2014.996243] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
57
|
Takada S, Weiser SD, Kumbakumba E, Muzoora C, Martin JN, Hunt PW, Haberer JE, Kawuma A, Bangsberg DR, Tsai AC. The dynamic relationship between social support and HIV-related stigma in rural Uganda. Ann Behav Med 2015; 48:26-37. [PMID: 24500077 DOI: 10.1007/s12160-013-9576-5] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cross-sectional studies show that human immunodeficiency virus (HIV) stigma is negatively correlated with social support. PURPOSE The purpose of this study is to examine the bidirectional relationship between social support and HIV stigma. METHODS We collected quarterly data from a cohort of 422 people living with HIV in Uganda, followed for a median of 2.1 years. We used multilevel regression to model the contemporaneous and 3-month-lagged associations between social support and both enacted and internalized stigma. RESULTS Lagged enacted stigma was negatively correlated with emotional and instrumental social support, and lagged instrumental social support was negatively correlated with enacted stigma. Internalized stigma and emotional social support had reciprocal lagged associations. CONCLUSIONS Interventions to reduce enacted stigma may strengthen social support for people living with HIV. Improved social support may in turn have a protective influence against future enacted and internalized stigma.
Collapse
Affiliation(s)
- Sae Takada
- Harvard Medical School, Boston, MA, USA,
| | | | | | | | | | | | | | | | | | | |
Collapse
|
58
|
Ogoina D, Ikuabe P, Ebuenyi I, Harry T, Inatimi O, Chukwueke O. Types and predictors of partner reactions to HIV status disclosure among HIV-infected adult Nigerians in a tertiary hospital in the Niger Delta. Afr Health Sci 2015; 15:10-8. [PMID: 25834525 PMCID: PMC4370137 DOI: 10.4314/ahs.v15i1.2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Our aim was to describe the types and determinants of partner reactions to HIV-status disclosure among adults attending an antiretroviral therapy-(ART) clinic in the Bayelsa State, Nigeria. METHODS A cross-sectional study was undertaken between January and March 2013 among consecutive adult patients who had disclosed their HIV-status to their current sexual partner. Sociodemograhic data and types of initial and subsequent partner reactions to disclosure were obtained using interviewer-administered standardized-questionnaire. Independent determinants of reactions to disclosure were ascertained by unconditional logistic regression. RESULTS Out of 123 study participants, 57.7% were females, 92% were receiving ART and 86.1% were currently married. Majority of the participants reported predominant positive or supportive initial (72.4%) and subsequent (89.5%) partner reactions to disclosure, with significant increase in positive reactions over time. Positive initial partner reactions were independently associated with prior post-test counselling-(Odds ratio [OR]-6.5, 95% Confidence interval [CI]-1.3-31.6-p=0.02), age>35 years-(OR-5.8, 95% CI-1.6-20.9-p=0.008) and being healthy at time of disclosure-(OR-7.8, 95% CI-1.7-35.4-p=0.008). Subsequent positive partner reactions were significantly associated with receiving antiretroviral therapy and having only one lifetime sexual partner. CONCLUSION Our results indicate that partner reactions to HIV-status disclosure are predominantly supportive. Disclosure counselling and early initiation of ART may be effective in improving HIV-status disclosure in Nigeria.
Collapse
Affiliation(s)
- Dimie Ogoina
- Department of Medicine and Heart to Heart Clinic, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state
| | - Peter Ikuabe
- Department of Medicine and Heart to Heart Clinic, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state
| | - Ikenna Ebuenyi
- Department of Medicine and Heart to Heart Clinic, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state
| | - Tubonye Harry
- Department of Medicine and Heart to Heart Clinic, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state
| | - Otonyo Inatimi
- Department of Medicine and Heart to Heart Clinic, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state
| | - Ogechi Chukwueke
- Department of Medicine and Heart to Heart Clinic, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa state
| |
Collapse
|
59
|
Socioeconomic gradients in internalized stigma among 4,314 persons with HIV in sub-Saharan Africa. AIDS Behav 2015; 19:270-82. [PMID: 25572833 DOI: 10.1007/s10461-014-0993-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The stigma attached to HIV is a major public health problem given its adverse impacts on HIV prevention and on the psychosocial wellbeing of persons with HIV. In this study, I apply a novel method to data from the Demographic and Health Surveys to identify persons with HIV who were aware of their seropositivity at the time of the survey. The pooled dataset includes 4,314 persons with HIV in Cameroon, Ethiopia, Gabon, Kenya, Lesotho, Malawi, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. My findings indicate that nearly one-fifth of study participants provided survey responses consistent with internalization of stigmatizing beliefs. Furthermore, in multivariable regression models, striking socioeconomic gradients in internalized stigma were observed. A clear implication of my findings is that the adverse health and psychosocial impacts of HIV stigma are likely concentrated among those with the fewest socioeconomic resources for managing and resisting it.
Collapse
|
60
|
Depression during pregnancy and the postpartum among HIV-infected women on antiretroviral therapy in Uganda. J Acquir Immune Defic Syndr 2015; 67 Suppl 4:S179-87. [PMID: 25436816 PMCID: PMC4251908 DOI: 10.1097/qai.0000000000000370] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Supplemental Digital Content is Available in the Text. Background: Among HIV-infected women, perinatal depression compromises clinical, maternal, and child health outcomes. Antiretroviral therapy (ART) is associated with lower depression symptom severity but the uniformity of effect through pregnancy and postpartum periods is unknown. Methods: We analyzed prospective data from 447 HIV-infected women (18–49 years) initiating ART in rural Uganda (2005–2012). Participants completed blood work and comprehensive questionnaires quarterly. Pregnancy status was assessed by self-report. Analysis time periods were defined as currently pregnant, postpartum (0–12 months post-pregnancy outcome), or non–pregnancy-related. Depression symptom severity was measured using a modified Hopkins Symptom Checklist 15, with scores ranging from 1 to 4. Probable depression was defined as >1.75. Linear regression with generalized estimating equations was used to compare mean depression scores over the 3 periods. Results: At enrollment, median age was 32 years (interquartile range: 27–37), median CD4 count was 160 cells per cubic millimeter (interquartile range: 95–245), and mean depression score was 1.75 (s = 0.58) (39% with probable depression). Over 4.1 median years of follow-up, 104 women experienced 151 pregnancies. Mean depression scores did not differ across the time periods (P = 0.75). Multivariable models yielded similar findings. Increasing time on ART, viral suppression, better physical health, and “never married” were independently associated with lower mean depression scores. Findings were consistent when assessing probable depression. Conclusions: Although the lack of association between depression and perinatal periods is reassuring, high depression prevalence at treatment initiation and continued incidence across pregnancy and non–pregnancy-related periods of follow-up highlight the critical need for mental health services for HIV-infected women to optimize both maternal and perinatal health.
Collapse
|
61
|
Persistent HIV-related stigma in rural Uganda during a period of increasing HIV incidence despite treatment expansion. AIDS 2015; 29:83-90. [PMID: 25268886 DOI: 10.1097/qad.0000000000000495] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Programme implementers have argued that the increasing availability of antiretroviral therapy (ART) will reduce the stigma of HIV. We analyzed data from Uganda to assess how HIV-related stigma has changed during a period of ART expansion. DESIGN Serial cross-sectional surveys. METHODS We analyzed data from the Uganda AIDS Rural Treatment Outcomes study during 2007-2012 to estimate trends in internalized stigma among people living with HIV (PLHIV) at the time of treatment initiation. We analyzed data from the Uganda Demographic and Health Surveys from 2006 to 2011 to estimate trends in stigmatizing attitudes and anticipated stigma in the general population. We fitted regression models adjusted for sociodemographic characteristics, with year of data collection as the primary explanatory variable. RESULTS We estimated an upward trend in internalized stigma among PLHIV presenting for treatment initiation [adjusted b = 0.18; 95% confidence interval (CI), 0.06-0.30]. In the general population, the odds of reporting anticipated stigma were greater in 2011 compared with 2006 [adjusted odds ratio (OR) = 1.80; 95% CI, 1.51-2.13], despite an apparent decline in stigmatizing attitudes (adjusted OR = 0.62; 95% CI, 0.52-0.74). CONCLUSION Internalized stigma has increased over time among PLHIV in the setting of worsening anticipated stigma in the general population. Further study is needed to better understand the reasons for increasing HIV-related stigma in Uganda and its impact on HIV prevention efforts.
Collapse
|
62
|
Turan B, Stringer KL, Onono M, Bukusi EA, Weiser SD, Cohen CR, Turan JM. Linkage to HIV care, postpartum depression, and HIV-related stigma in newly diagnosed pregnant women living with HIV in Kenya: a longitudinal observational study. BMC Pregnancy Childbirth 2014; 14:400. [PMID: 25467187 PMCID: PMC4261547 DOI: 10.1186/s12884-014-0400-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 11/19/2014] [Indexed: 12/30/2022] Open
Abstract
Background While studies have suggested that depression and HIV-related stigma may impede access to care, a growing body of literature also suggests that access to HIV care itself may help to decrease internalized HIV-related stigma and symptoms of depression in the general population of persons living with HIV. However, this has not been investigated in postpartum women living with HIV. Furthermore, linkage to care itself may have additional impacts on postpartum depression beyond the effects of antiretroviral therapy. We examined associations between linkage to HIV care, postpartum depression, and internalized stigma in a population with a high risk of depression: newly diagnosed HIV-positive pregnant women. Methods In this prospective observational study, data were obtained from 135 HIV-positive women from eight antenatal clinics in the rural Nyanza Province of Kenya at their first antenatal visit (prior to testing HIV-positive for the first time) and subsequently at 6 weeks after giving birth. Results At 6 weeks postpartum, women who had not linked to HIV care after testing positive at their first antenatal visit had higher levels of depression and internalized stigma, compared to women who had linked to care. Internalized stigma mediated the effect of linkage to care on depression. Furthermore, participants who had both linked to HIV care and initiated antiretroviral therapy reported the lowest levels of depressive symptoms. Conclusions These results provide further support for current efforts to ensure that women who are newly diagnosed with HIV during pregnancy become linked to HIV care as early as possible, with important benefits for both physical and mental health.
Collapse
Affiliation(s)
- Bulent Turan
- Department of Psychology, University of Alabama at Birmingham, CH 415, 1530 3rd Avenue South, Birmingham, AL, 35294-1170, USA.
| | - Kristi L Stringer
- Department of Sociology, University of Alabama at Birmingham, HHB 460, 1720 2nd Ave South, Birmingham, AL, 35294-1152, USA.
| | - Maricianah Onono
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.
| | - Elizabeth A Bukusi
- Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), Nairobi, Kenya.
| | - Sheri D Weiser
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA.
| | - Craig R Cohen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA.
| | - Janet M Turan
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
| |
Collapse
|
63
|
Tsai AC. Reliability and validity of depression assessment among persons with HIV in sub-Saharan Africa: systematic review and meta-analysis. J Acquir Immune Defic Syndr 2014; 66:503-11. [PMID: 24853307 PMCID: PMC4096047 DOI: 10.1097/qai.0000000000000210] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to systematically review the reliability and validity of instruments used to screen for major depressive disorder or assess depression symptom severity among persons with HIV in sub-Saharan Africa. DESIGN Systematic review and meta-analysis. METHODS A systematic evidence search protocol was applied to 7 bibliographic databases. Studies examining the reliability and/or validity of depression assessment tools were selected for inclusion if they were based on the data collected from HIV-positive adults in any African member state of the United Nations. A random-effects meta-analysis was used to calculate pooled estimates of depression prevalence. In a subgroup of studies of criterion-related validity, the bivariate random-effects model was used to calculate pooled estimates of sensitivity and specificity. RESULTS Of 1117 records initially identified, I included 13 studies of 5373 persons with HIV in 7 sub-Saharan African countries. Reported estimates of Cronbach alpha ranged from 0.63 to 0.95, and analyses of internal structure generally confirmed the existence of a depression-like construct accounting for a substantial portion of variance. The pooled prevalence of probable depression was 29.5% [95% confidence interval (CI): 20.5 to 39.4], whereas the pooled prevalence of major depressive disorder was 13.9% (95% CI: 9.7 to 18.6). The Center for Epidemiologic Studies Depression scale was the most frequently studied instrument, with a pooled sensitivity of 0.82 (95% CI: 0.73 to 0.87) for detecting major depressive disorder. CONCLUSIONS Depression-screening instruments yielded relatively high false positive rates. Overall, few studies described the reliability and/or validity of depression instruments in sub-Saharan Africa.
Collapse
Affiliation(s)
- Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital (MGH), Boston, United States
- MGH Center for Global Health, Boston, United States
- Harvard Medical School, Boston, United States
- Mbarara University of Science and Technology, Mbarara, Uganda
| |
Collapse
|
64
|
Hahn JA, Fatch R, Wanyenze RK, Baveewo S, Kamya MR, Bangsberg DR, Coates TJ. Decreases in self-reported alcohol consumption following HIV counseling and testing at Mulago Hospital, Kampala, Uganda. BMC Infect Dis 2014; 14:403. [PMID: 25038830 PMCID: PMC4223423 DOI: 10.1186/1471-2334-14-403] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 07/10/2014] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Alcohol use has a detrimental impact on the HIV epidemic, especially in sub-Saharan Africa. HIV counseling and testing (HCT) may provide a contact opportunity to intervene with hazardous alcohol use; however, little is known about how alcohol consumption changes following HCT. METHODS We utilized data from 2056 participants of a randomized controlled trial comparing two methods of HCT and subsequent linkage to HIV care conducted at Mulago Hospital in Kampala, Uganda. Those who had not previously tested positive for HIV and whose last HIV test was at least one year in the past were eligible. Participants were asked at baseline when they last consumed alcohol, and prior three month alcohol consumption was measured using the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C) at baseline and quarterly for one year. Hazardous alcohol consumption was defined as scoring ≥3 or ≥4 for women and men, respectively. We examined correlates of alcohol use at baseline, and of hazardous and non-hazardous drinking during the year of follow-up using multinomial logistic regression, clustered at the participant level to account for repeated measurements. RESULTS Prior to HCT, 30% were current drinkers (prior three months), 27% were past drinkers (>3 months ago), and 44% were lifetime abstainers. One-third (35%) of the current drinkers met criteria for hazardous drinking. Hazardous and non-hazardous self-reported alcohol consumption declined after HCT, with 16% of baseline current drinkers reporting hazardous alcohol use 3 months after HCT. Independent predictors (p < 0.05) of continuing non-hazardous and hazardous alcohol consumption after HCT were sex (male), alcohol consumption prior to HCT (hazardous), and HIV status (negative). Among those with HIV, non-hazardous drinking was less likely among those taking antiretroviral therapy (ART). CONCLUSIONS HCT may be an opportune time to intervene with alcohol consumption. Those with HIV experienced greater declines in alcohol consumption after HCT, and non-hazardous drinking decreased for those with HIV initiating ART. HCT and ART initiation may be ideal times to intervene with alcohol consumption. Screening and brief intervention (SBI) to reduce alcohol consumption should be considered for HCT and HIV treatment venues.
Collapse
Affiliation(s)
- Judith A Hahn
- University of California, San Francisco, Box 0886, San Francisco, CA 94143-0886, USA.
| | | | | | | | | | | | | |
Collapse
|
65
|
Internalized stigma, social distance, and disclosure of HIV seropositivity in rural Uganda. Ann Behav Med 2014; 46:285-94. [PMID: 23690283 DOI: 10.1007/s12160-013-9514-6] [Citation(s) in RCA: 117] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND HIV is highly stigmatized, compromising both treatment and prevention in resource-limited settings. PURPOSE We sought to study the relationship between internalized HIV-related stigma and serostatus disclosure and to determine the extent to which this association varies with the degree of social distance. METHODS We fit multivariable Poisson regression models, with cluster-correlated robust estimates of variance, to data from 259 persons with HIV enrolled in an ongoing cohort study in rural Uganda. RESULTS Persons with more internalized stigma were less likely to disclose their seropositivity. The magnitude of association increased with social distance such that the largest association was observed for public disclosures and the smallest association was observed for disclosures to sexual partners. CONCLUSIONS Among persons with HIV in rural Uganda, internalized stigma was negatively associated with serostatus disclosure. The inhibiting effect of stigma was greatest for the most socially distant ties.
Collapse
|
66
|
Martinez P, Tsai AC, Muzoora C, Kembabazi A, Weiser SD, Huang Y, Haberer JE, Martin JN, Bangsberg DR, Hunt PW. Reversal of the Kynurenine pathway of tryptophan catabolism may improve depression in ART-treated HIV-infected Ugandans. J Acquir Immune Defic Syndr 2014; 65:456-62. [PMID: 24220289 PMCID: PMC3943704 DOI: 10.1097/qai.0000000000000062] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Major depressive disorder is highly prevalent among HIV-infected persons, and depression symptom severity improves during the course of HIV antiretroviral therapy (ART). The potential biologic pathways explaining these phenomena remain unclear. We investigated the extent to which ART-mediated suppression of the kynurenine pathway of tryptophan catabolism (via indoleamine 2,3-dioxygenase-1 and potentially other sources) may correlate with improvements in depression symptom severity in this setting. METHOD We used the first year of data from the Uganda AIDS Rural Treatment Outcomes Study, a prospective cohort of 504 HIV-infected individuals initiating their first ART regimen in rural Uganda. We fitted random-effects regression models to estimate the associations between plasma tryptophan, plasma kynurenine, dietary diversity, and self-reported depression symptom severity. RESULTS Greater depressive symptoms were associated with both lower plasma tryptophan and higher plasma kynurenine/tryptophan (KT) ratio over 12-month follow-up. In multivariable-adjusted models, declines in KT ratio and increases in plasma tryptophan levels partially explained ART-mediated improvements in depressive symptom severity. The association between KT ratio and depression symptom severity was stronger among persons with protein-deficient diets than among those with protein-rich diets. CONCLUSIONS Indoleamine 2,3-dioxygenase-1-mediated tryptophan catabolism may contribute to depression symptom severity among HIV-infected individuals, particularly among those with poor dietary protein intake. ART-mediated improvements in depressive symptom severity may also be at least partially mediated by immunologic mechanisms. Interventions to reduce immune activation, and dietary protein supplementation, may be promising strategies to further reduce depression in this setting.
Collapse
Affiliation(s)
- Priscilla Martinez
- Norwegian Center for Addiction Research, University of Oslo, Oslo, Norway
- Alcohol Research Group, School of Public Health, University of California, Berkeley, CA, USA
| | - Alexander C. Tsai
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
- Chester M. Pierce MD Division of Global Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Conrad Muzoora
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Annet Kembabazi
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - Yong Huang
- University of California at San Francisco, CA, USA
| | - Jessica E. Haberer
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
| | - Jeffrey N. Martin
- University of California at San Francisco, CA, USA
- Division of HIV/AIDS, San Francisco General Hospital, University of California San Francisco, CA, USA
| | - David R. Bangsberg
- Massachusetts General Hospital Center for Global Health, Boston, MA, USA
- Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Department of Global Health and Population, Harvard School of Public Health
- Ragon Institute of Massachusetts General Hospital, MIT and Harvard, Boston, MA, USA
| | - Peter W. Hunt
- University of California at San Francisco, CA, USA
- Division of HIV/AIDS, San Francisco General Hospital, University of California San Francisco, CA, USA
| |
Collapse
|
67
|
'If I am given antiretrovirals I will think I am nearing the grave': Kenyan HIV serodiscordant couples' attitudes regarding early initiation of antiretroviral therapy. AIDS 2014; 28:227-33. [PMID: 24413310 DOI: 10.1097/qad.0000000000000025] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Early initiation of antiretroviral therapy (ART) - that is, at higher CD4 cell counts (>350 cells/μl) - is a potent HIV prevention strategy. The WHO recommends ART initiation by all HIV-infected individuals in HIV serodiscordant relationships to prevent HIV transmission, yet the acceptability of early ART among couples has not been well studied. DESIGN Qualitative study exploring HIV serodiscordant couples' attitudes toward early initiation of ART. METHODS We conducted eight focus group discussions and 20 in-depth interviews with members of heterosexual HIV serodiscordant couples in Kenya. Investigators iteratively applied inductive and deductive codes, developed matrices to identify patterns in codes, and reached consensus on key attitudes (motivations and barriers) related to early ART and one central, emerging theme. RESULTS Most participants expressed interest in early initiation of ART, with maintaining health and preventing HIV transmission as key benefits. However, many identified personal concerns and potential barriers to wider community acceptance, including side-effects, adherence to life-long treatment, and stigma. The meaning of ART emerged as a fundamental consideration, with initiating therapy perceived as emblematic of the final stage of AIDS, when one was 'nearing the grave.' One particular challenge was what early ART might signify for someone who looks and feels healthy. CONCLUSION HIV serodiscordant couples recognized the potential benefits of early ART, but ART was frequently viewed as signifying AIDS and approaching mortality. Potential implementation of early ART presents challenges and an opportunity to re-orientate individuals toward a new image of ART as health-preserving for patients and partners.
Collapse
|
68
|
|
69
|
Resisting and challenging stigma in Uganda: the role of support groups of people living with HIV. J Int AIDS Soc 2013; 16:18636. [PMID: 24242256 PMCID: PMC3833188 DOI: 10.7448/ias.16.3.18636] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Revised: 08/22/2013] [Accepted: 08/29/2013] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Global scale up of antiretroviral therapy is changing the context of HIV-related stigma. However, stigma remains an ongoing concern in many countries. Groups of people living with HIV can contribute to the reduction of stigma. However, the pathways through which they do so are not well understood. METHODS This paper utilizes data from a qualitative study exploring the impact of networked groups of people living with HIV in Jinja and Mbale districts of Uganda. Participants were people living with HIV (n=40), members of their households (n=10) and their health service providers (n=15). Data were collected via interviews and focus group discussions in 2010, and analyzed inductively to extract key themes related to the approaches and outcomes of the groups' anti-stigma activities. RESULTS Study participants reported that HIV stigma in their communities had declined as a result of the collective activities of groups of people living with HIV. However, they believed that stigma remained an ongoing challenge. Gender, family relationships, social and economic factors emerged as important drivers of stigma. Challenging stigma collectively transcended individual experiences and united people living with HIV in a process of social renegotiation to achieve change. Groups of people living with HIV provided peer support and improved the confidence of their members, which ultimately reduced self-stigma and improved their ability to deal with external stigma when it was encountered. CONCLUSIONS Antiretroviral therapy and group-based approaches in the delivery of HIV services are opening up new avenues for the collective participation of people living with HIV to challenge HIV stigma and act as agents of social change. Interventions for reducing HIV stigma should be expanded beyond those that aim to increase the resilience and coping mechanisms of individuals, to those that build the capacity of groups to collectively cope with and challenge HIV stigma. Such interventions should be gender sensitive and should respond to contextual social, economic and structural factors that drive stigma.
Collapse
|
70
|
Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc 2013; 16:18640. [PMID: 24242258 PMCID: PMC3833107 DOI: 10.7448/ias.16.3.18640] [Citation(s) in RCA: 715] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 08/22/2013] [Accepted: 08/29/2013] [Indexed: 01/20/2023] Open
Abstract
Introduction Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence. Methods We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies. Results Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants’ ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ2=7.7; p=0.005). Conclusions We found that HIV-related stigma compromised participants’ abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.
Collapse
|
71
|
Abstract
Alexander Tsai and colleagues highlight the complex relationship between poverty and HIV stigma in sub-Saharan Africa, and discuss possible ways to break the cycle. Please see later in the article for the Editors' Summary.
Collapse
Affiliation(s)
- Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
| | - David R. Bangsberg
- Harvard Medical School, Boston, Massachusetts, United States of America
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts, United States of America
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - Sheri D. Weiser
- Division of HIV/AIDS, San Francisco General Hospital, University of California at San Francisco, San Francisco, California, United States of America
| |
Collapse
|