Mental health and HIV/AIDS: the need for an integrated response

Roll-out of HIV pre-exposure prophylaxis: a gateway to mental health promotion

HIV remains a pressing global health problem, with 1.5 million new infections reported globally in 2020. HIV pre-exposure prophylaxis (PrEP) can lower the likelihood of HIV acquisition among populations at elevated risk, yet its global roll-out has been discouragingly slow. Psychosocial factors, such as co-occurring mental illness and substance use, are highly prevalent among populations likely to benefit from PrEP, and have been shown to undermine persistence and adherence. In this analysis, we review the high burden of mental health problems among PrEP candidates and contend that inattention to mental health stands to undermine efforts to implement PrEP on a global scale. We conclude that integration of mental health screening and treatment within PrEP scale-up efforts represents an important strategy for maximising PrEP effectiveness while addressing the high burden of mental illness among at-risk populations. As implementers seek to integrate mental health services within PrEP services, efforts to keep access to PrEP as low-threshold as possible should be maintained. Moreover, programmes should seek to implement mental health interventions that are sensitive to local resource constraints and seek to reduce intersecting stigmas associated with HIV and mental illness.

Disability and self-care living strategies among adults living with HIV during the COVID-19 pandemic

BACKGROUND

Events associated with the COVID-19 pandemic, such as physical distancing, closure of community services, postponement of health appointments, and loss of employment can lead to social isolation, financial uncertainty, and interruption of antiretroviral adherence, resulting in additional health-related challenges (disability) experienced among adults living with chronic illness such as HIV. 'Living strategies' is a concept derived from the perspectives of people living with HIV, defined as behaviors, attitudes and beliefs adopted by people living with HIV to help deal with disability associated with HIV and multi-morbidity. Our aim was to describe disability among adults living with HIV and self-care living strategies used during the COVID-19 pandemic.

METHODS

Adults living with HIV in Toronto, Ontario, Canada, including some with pre-pandemic HIV Disability Questionnaire (HDQ) data, completed a cross-sectional web-based survey between June-August 2020. The survey included the HDQ and questions about self-care living strategy use during the pandemic. We compared disability (HDQ) scores prior to versus during the pandemic using paired t-tests. We reported the proportion of participants who engaged in various living strategies at least 'a few times a week' or 'everyday' during the pandemic.

RESULTS

Of the 63 respondents, 84% were men, median age 57 years, and 62% lived alone. During the pandemic the greatest disability severity was in the uncertainty [median 30; Interquartile range (IQR): 16, 43] and mental-emotional (25; IQR: 14, 41) domains. Among the 51 participants with pre-pandemic data, HDQ severity scores were significantly greater (worse) during the pandemic (vs prior) in all domains. Greatest change from prior to during the pandemic was in the mental-emotional domain for presence (17.7; p < 0.001), severity (11.4; p < 0.001), and episodic nature (9.3; p < 0.05) of disability. Most participants (> 60%) reported engaging a 'few times a week' or 'everyday' in self-care strategies associated with maintaining sense of control and adopting positive attitudes and beliefs.

CONCLUSIONS

People living with HIV reported high levels of uncertainty and mental-emotional health challenges during the pandemic. Disability increased across all HDQ dimensions, with the greatest worsening in the mental-emotional health domain. Results provide an understanding of disability and self-care strategy use during the COVID-19 pandemic.

Mediating Effects of Stigma and Depressive Symptoms in a Social Media-Based Intervention to Improve Long-term Quality of Life Among People Living With HIV: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Mobile health (mHealth) interventions have been shown to effectively improve the quality of life (QOL) among people living with HIV. However, little is known about the long-term effects of mHealth interventions.

OBJECTIVE

This study aims to explore the intervention mechanisms of a social media-based intervention, Run4Love, on the QOL of people with HIV over across a 9-month follow-up period.

METHODS

We recruited people living with HIV who were concurrently experiencing elevated depressive symptoms from an HIV outpatient clinic in South China. A total of 300 eligible participants were randomized either to the intervention group or the control group in a 1:1 ratio after they provided informed consent and completed a baseline survey. The intervention group received a 3-month WeChat-based intervention, comprising cognitive-behavioral stress management (CBSM) courses and physical activity promotion. The control group received a printed brochure on nutrition guidelines in addition to the usual care for HIV treatment. Neither participants nor the research staff were blinded to group assignment. All patients were followed at 3, 6, and 9 months. The primary outcome was depressive symptoms. Structural equation model (SEM) with longitudinal data was conducted to examine the sequential mediating effects of HIV-related stigma and depressive symptoms on the long-term intervention effects on participants' QOL.

RESULTS

About 91.3% (274/300), 88.3% (265/300), and 86.7% (260/300) of all participants completed follow-up surveys at 3, 6, and 9 months, respectively. Results showed that the intervention had significantly improved participants' QOL at 9 months, via complete mediating effects of reduced HIV-related stigma at 3 months and decreased depressive symptoms at 6 months. No adverse events were reported.

CONCLUSIONS

These findings underscore the critical roles of HIV-related stigma and depressive symptoms in an mHealth intervention with long-term effects on QOL improvements. We call for targeted mHealth interventions to improve QOL among people living with HIV, especially social media-based interventions that can address HIV-related stigma and alleviate depressive symptoms.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://www.chictr.org.cn/showproj.aspx?proj=21019.

Relationship Between Mental Health and HIV Transmission Knowledge and Prevention Attitudes Among Adolescents Living with HIV: Lessons from Suubi + Adherence Cluster Randomized Study in Southern Uganda

We assessed the effect of depression, hopelessness, and self-concept on HIV prevention attitudes and knowledge about infection, transmission and sexual risk behavior among adolescents living with HIV in Uganda. Utilizing longitudinal data from 635 adolescents living with HIV, multiple ordinary least square regression was used to evaluate associations between the three indicators of mental health functioning at baseline and HIV knowledge and prevention attitudes at 12-months follow-up. We found that depression (β = - 0.17; 95% CI - 0.31, - 0.04) and hopelessness (β = - 0.16; 95% CI - 0.28, - 0.04) scores at baseline were associated with a 0.17 and 0.16 average reduction in HIV prevention attitudes and HIV knowledge scores, respectively at 12-months follow-up. However, self-concept was not significantly associated with HIV knowledge or prevention attitudes. Adolescents living with HIV with greater levels of hopelessness are at increased risk of having limited HIV knowledge while those with greater symptoms of depression had less favorable HIV prevention attitudes.

Mental health care in Eastern Europe and Central Asia: An analysis of needs and a call for greater investment

Over the past decade, there has been increased attention to global mental health, which emphasizes improving access to quality mental health care in order to reduce the worldwide treatment gap. However, Eastern European and Central Asian countries and their specific mental health needs have largely been under-emphasized, evidenced by a dearth in literature and funding. Here, we provide an overview of the mental health needs in Ukraine and its challenges with quality care provision as a key example in highlighting these gaps, then broaden our discussion to include parallels with other countries in the Eastern European and Central Asian region. We describe the unique strengths relative to mental health care provision that are present in Eastern Europe and Central Asia and suggest the importance of post-graduate training, regional collaboration, and capacity building specific to research management as strategies to address the current challenges. We stress that greater investment from funders, government, and the global mental health community are needed to improve the current mental health situation in Ukraine, specifically, and Eastern Europe and Central Asia, broadly. We argue that greater attention to Eastern Europe and Central Asia is needed to fully advance the agenda of the global mental health field.

Stigma, Social Cohesion, and Mental Health Among Transgender Women Sex Workers Living with HIV in the Dominican Republic

Globally, transgender (trans) women experience pervasive stigma, which contributes to health inequities across multiple mental health outcomes. While trans stigma has been associated with increased mental health challenges, less is known about how stigma related to sex work and HIV affect mental health. Social cohesion may ameliorate the negative health consequences of stigma, but little is known about how social cohesion is associated with mental health among trans women. Using cross-sectional survey data collected in 2019 among 100 trans women sex workers living with HIV in Santo Domingo, Dominican Republic, we examined associations between stigma (related to HIV, sex work, and trans identity), social cohesion, and depression and anxiety symptoms. In unadjusted models, enacted and internalized sex work stigma were associated with greater odds of depression and anxiety symptoms and social cohesion was associated with less depression and anxiety. Resisted sex work stigma, which captured acceptance of self and work, was associated with lower odds of depression and trans stigma was associated with increased anxiety. In adjusted models, internalized sex work stigma was associated with increased depression (aOR=1.19, p=0.018) and anxiety symptoms (aOR=1.12, p=0.021), while social cohesion was associated with reduced depression (OR=0.81, p=0.002) and anxiety symptoms (aOR=0.086, p=0.023). Findings indicate the need for interventions to focus on reducing internalized sex work stigma and promoting social cohesion to improve mental health among trans women. Additional research is needed to determine how to best measure the intersections between HIV, sex work, and trans stigma and their impact on mental health.

A Scoping Review Investigating Relationships between Depression, Anxiety, and the PrEP Care Continuum in the United States

Men who have sex with men and transgender women in the United States are at increased risk for HIV and may benefit from pre-exposure prophylaxis (PrEP), a once-a-day pill to prevent HIV. Due to stigma and discrimination, sexual and gender minority (SGM) populations are also at risk for depression and anxiety. This scoping review sought to identify literature addressing relationships between the PrEP care continuum, depression, and anxiety among SGM individuals and others at high risk for HIV. We conducted a systematic review of four databases (i.e., PubMed, PsycInfo, Web of Science, Google Scholar) and identified 692 unique articles that were screened for inclusion criteria, with 51 articles meeting the final inclusion criteria. Data were extracted for key study criteria (e.g., geographic location, participant demographics, study design, main findings). Results suggest that while depression and anxiety are not associated with PrEP awareness or willingness to use, they can be barriers to seeking care and to PrEP adherence. However, empirical studies show that taking PrEP is associated with reductions in anxiety. Findings suggest the need to implement mental health screenings in PrEP clinical care. In addition, addressing systemic and structural issues that contribute to mental health disorders, as well as PrEP-related barriers, is critical.

Disability and Self-care Living Strategies Among Adults Living With HIV During the COVID-19 Pandemic

BackgroundEvents associated with the COVID-19 pandemic, such as physical distancing, closure of community services, postponement of health appointments, and loss of employment can lead to social isolation, financial uncertainty, and interruption of antiretroviral adherence, resulting in additional health-related challenges (disability) experienced among adults living with chronic illness such as HIV. 'Living strategies' is a concept derived from the perspective of people living with HIV, defined as behaviors, attitudes and beliefs adopted by people living with HIV to help deal with disability associated with HIV and multi-morbidity. Our aim was to describe disability among adults living with HIV and self-care living strategies used during the COVID-19 pandemic. MethodsAdults living with HIV in Toronto, Ontario, Canada, including some with pre-pandemic HIV Disability Questionnaire (HDQ) data, completed a cross-sectional web-based survey between June-August 2020. The survey included the HDQ and questions about self-care living strategy use during the pandemic. We compared disability (HDQ) scores prior to versus during the pandemic using paired t-tests. We reported the proportion of participants who engaged in various living strategies at least 'a few times a week' or 'everyday' during the pandemic. ResultsOf the 63 respondents, 84% were men, median age 57 years, and 62% lived alone. During the pandemic the greatest disability severity was in the uncertainty (median 30; Interquartile range (IQR): 16, 43) and mental-emotional (25; IQR: 14, 41) domains. Among the 51 participants with pre-pandemic data, HDQ severity scores were significantly greater (worse) during the pandemic (vs prior) in all domains. Greatest change from prior to during the pandemic was in the mental-emotional domain for presence (17.7; p<0.001), severity (11.4; p<0.001), and episodic nature (9.3; p<0.05) of disability. Most participants (>60%) reported engaging a 'few times a week' or 'everyday' in self-care strategies associated with maintaining sense of control and adopting positive attitudes and beliefs. ConclusionsPeople living with HIV reported high levels of uncertainty and mental-emotional health challenges during the pandemic. Disability increased across all HDQ dimensions, with the greatest worsening in the mental-emotional health domain. Results provide an understanding of disability and self-care strategy use during the COVID-19 pandemic.

Global collective action in mental health financing: Allocation of development assistance for mental health in 142 countries, 2000-2015

Collective action between international donors is central to the mobilisation of global solidarity in global health. This is especially important in mental health where resources remain extremely limited. In this paper I investigate global collective action in mental health financing, looking at the responsiveness of international donors to mental health needs in low- and middle-income countries (LMICs). I analyse factors at the level of recipient countries (needs, interests, policy environment) associated with allocation of development assistance for mental health (DAMH) using a two-part regression model applied to a time series cross-sectional dataset of 142 LMICs between 2000 and 2015. Findings reveal that international donors' disbursements are not well aligned with mental health needs of recipient countries, and, moreover, contextual factors might be playing more prominent roles in resource allocation. Countries are more likely to receive DAMH if they experience significant outbreaks of infectious diseases or have lower gross domestic product (GDP) per capita and lower market openness. Selected recipient countries are more likely to receive higher DAMH amounts per capita if they have lower GDP per capita, higher government health expenditure, or higher mortality rates due to conflicts or natural disasters. Past DAMH recipients are more likely to be selected and, when selected, to receive higher DAMH amounts per capita. My results demonstrate that more holistic collective action amongst international donors is required to address mental health needs in LMICs. Investments should better reflect needs, particularly during and after emergencies such as COVID-19, and could be amplified by leveraging synergies across other health conditions and sectors.

Ending the HIV Epidemic: One Southern Community Speaks

Memphis, Tennessee and its surrounding counties have been profoundly affected by the HIV epidemic. Using a participatory research approach this study identified from a community perspective: 1) the barriers and facilitators for providing support to achieve viral suppression to the most at-risk groups living with HIV in the Memphis Transitional Grant Area and 2) opportunities to strengthen the health care system through the use of community health workers (CHWs) to do outreach and engage with people living with HIV. Themes of barriers include intersectional stigma, HIV criminal laws, abstinence-only sex education, housing, transportation, and limited access to HIV case management and mental health services. Strategies to address these barriers included HIV education to youth in schools and community-wide campaigns, more testing sites, involving faith leaders, funding for housing options, innovative transportation services, rapid start of culturally appropriate HIV medical treatment, intensive case management services, and mental health counseling. Two opportunities to utilize CHWs to address the barriers identified in this geographic area are as policy advocates and as an integrated member of the HIV primary care team. The findings of this study can inform a strategy to build the CHW workforce which may have widespread implications for ending the HIV epidemic in this geographic area and across the United States.

Development and external validation of a risk calculator to predict internalising symptoms among Ugandan youths affected by HIV

The aim of the study was to develop and externally validate a model to predict individualized risk of internalizing symptoms among AIDS-affected youths in low-resource settings in sub-Saharan Africa. Longitudinal data from 558 Ugandan adolescents orphaned by AIDS was used to develop our predictive model. Least Absolute Shrinkage and Selection Operator logistic regression was used to select the best subset of predictors using 10-fold cross-validation. External validation of the final model was conducted in a sample of 372 adolescents living with HIV in Uganda. Best predictors for internalizing symptoms were gender, family cohesion, social support, asset ownership, recent sexually transmitted infection (STI) diagnosis, physical health self-rating, and previous poor mental health; area under the curve (AUC)  = 72.2; 95% CI  = 67.9-76.5. For adolescents without history of internalizing symptoms, the AUC = 69.0, 95% CI = 63.4-74.6, and was best predicted by gender, drug use, social support, asset ownership, recent STI diagnosis, and physical health self-rating. Both models were well calibrated. External validation in adolescents living with HIV sample was similar, AUC = 69.7; 95% CI = 64.1-75.2. The model predicted internalizing symptoms among African AIDS-affected youth reasonably well and showed good generalizability. The model offers opportunities for the design of public health interventions addressing poor mental health among youth affected by HIV/AIDS.

Mental Health in Women Living With HIV: The Unique and Unmet Needs

Women living with HIV (WLWH) experience depression, anxiety, and posttraumatic stress symptoms at higher rates than their male counterparts and more often than HIV-unaffected women. These mental health issues affect not only the well-being and quality of life of WLWH, but have implications for HIV management and transmission prevention. Despite these ramifications, WLWH are under-treated for mental health concerns and they are underrepresented in the mental health treatment literature. In this review, we illustrate the unique mental health issues faced by WLWH such as a high prevalence of physical and sexual abuse histories, caregiving stress, and elevated internalized stigma as well as myriad barriers to care. We examine the feasibility and outcomes of mental health interventions that have been tested in WLWH including cognitive behavioral therapy, mindfulness-based interventions, and supportive counseling. Future research is required to address individual and systemic barriers to mental health care for WLWH.

Experiences of People Living With HIV in Community Based Exercise: A Qualitative Longitudinal Study

This qualitative longitudinal study examined the experiences of people living with HIV who engaged in a structured community-based exercise (CBE) program under the supervision of a fitness coach. Twenty people living with HIV were invited to participate in 3 semi-structured interviews over time. Participants engaged in exercise 3 times per week for 6 months with one weekly session supervised by a coach. Interviews were audio-recorded, transcribed verbatim and underwent longitudinal thematic analyses. Eleven participants were included representing a total of 30 interviews. Participants valued their experiences with the CBE program, particularly the motivation provided by the coach. Concerns about the environment, stigma and episodic health challenges affected their overall experience. To foster independence and promote self-management, health providers should consider these findings when encouraging CBE with people living with HIV. It is important to understand their goals and offer a variety of exercise options to meet their needs.

Immediate PrEP after PEP: Results from an Observational Nurse-Led PEP2PrEP Study

Patients who use post-exposure prophylaxis (PEP) are at ongoing risk for HIV acquisition after completing PEP. While the Centers for Disease Control and Prevention recommends pre-exposure prophylaxis (PrEP) use immediately after PEP, some practitioners are hesitant to offer PEP-to-PrEP (PEP2PrEP). We began offering PEP2PrEP in the sexually transmitted infection clinic in Ottawa, Canada on August 5, 2018. During the first 16 months of PEP2PrEP, 61 patients requested PEP and 46 were initiated; 30 of these patients agreed to PEP2PrEP and 26 followed through. None of our PEP patients had confirmed HIV exposures; all fulfilled the initiation criterion of condomless anal sex with a male partner of unknown HIV-status. During the study, the number of PEP requests and initiations was statistical unchanged, yet the seroconversion rate among patients who used PEP decreased from 1.7% pre-PEP2PrEP to 0% post-PEP2PrEP. Regarding follow-up, most discontinuations occurred between the PrEP intake and 1-month follow-up visit.

U.S. transgender women's preferences for microeconomic interventions to address structural determinants of HIV vulnerability: a qualitative assessment

Background

Transgender women in the United States (U.S.) experience a disproportionate burden of HIV infection and challenges to engagement in HIV prevention and care. This excess burden is driven by structural and economic inequities. Microeconomic interventions may be effective strategies for reducing HIV inequities for this population. However, few studies have explored transgender women’s preferences for microeconomic interventions to address structural determinants of HIV vulnerability.

Methods

We conducted individual interviews with 19 adult transgender women in 2 U.S. cities (Richmond, VA and St. Louis, MO) who reported one or more sexual risk behaviors and recent economic hardship related to employment/income, housing, or food security. Interviews were recorded, transcribed, and analyzed using thematic content analysis.

Results

The majority (74%) of transgender women were racial/ethnic minorities with mean age of 26.3 years. 89% were currently economically vulnerable; and 23% were employed full-time. 37% reported living with HIV. Participants expressed strong support for unrestricted vouchers, with many expressing the need for funds to support gender-affirming interventions. Assistance with how to budget and save and support for job acquisition, career planning, and employment sustainment were also preferred, including access to non-stigmatizing employment. Visible transgender leadership, group empowerment, and small (rather than large) numbers of participants were considered important aspects of intervention design for transgender women, including outreach through existing transgender networks to facilitate inclusion. Incorporating HIV counseling and testing to reduce vulnerability to HIV was acceptable. However, transgender women enrolled in the study preferred that HIV not be the focus of an intervention.

Conclusions

Flexible microeconomic interventions that support gender affirming interventions, improve financial literacy, and provide living-wage non-stigmatizing employment are desired by economically vulnerable transgender women. While not focused on HIV, such interventions have the potential to reduce the structural drivers of HIV vulnerability among transgender women.

Latent Class Analysis of Syndemic Factors Associated with Sustained Viral Suppression among Ryan White HIV/AIDS Program Clients in Miami, 2017

The study's objective was to identify the association between sustained viral suppression (all viral load tests < 200 copies/ml per year) and patterns of co-occurring risk factors including, mental health, substance use, sexual risk behavior, and adverse social conditions for people with HIV (PWH). Latent class analysis followed by multivariable logistic regression was conducted for 6554 PWH in the Miami-Dade County Ryan White Program during 2017, and a five-class model was selected. Compared to Class 1 (no risk factors), the odds of achieving sustained viral suppression was significantly lower for Class 2 (mental health) (aOR: 0.67; 95% CI 0.54-0.83), Class 3 (substance use and multiple sexual partners) (0.60; 0.47-0.76), Class 4 (substance use, multiple sexual partners, and domestic violence) (0.71; 0.55-0.93), and Class 5 (mental health, substance use, multiple sexual partners, domestic violence, and homelessness) (0.26; 0.19-0.35). Findings indicate the need for targeted interventions that address these syndemic factors.

Motivation and methods of external organisations investing in mental health in low-income and middle-income countries: a qualitative study

Mental disorders (including substance use disorders, dementia, and self-harm) account for a substantial burden of disease and economic costs in low-income and middle-income countries (LMICs), yet they attract little funding. External resources are urgently needed but evidence on investments is scarce. This Health Policy paper uses 35 elite interviews and documentary analyses to examine how and why external organisations have invested in mental health in LMICs over the past three decades, and how this investment has changed over time. Four levels are examined: organisations, source countries, recipient countries, and global landscape. Organisations have invested in numerous internal and external activities. Among the various factors shaping organisational decisions, actors (ie, individuals and organisations concerned with mental health) were the most salient at all four levels. To increase external organisation investments in mental health in LMICs, organisational leadership and understanding are crucial, along with increased political support in source and recipient countries, and a stronger governance structure at the global level.

Gendered Experiences of Living with HIV in Australia

Globally, women represent more than half the people living with HIV. This proportion varies by country, with an over-representation of HIV among men who have sex with men (MSM) in some regions. For example, in Australia, MSM account for over 60% of transmissions, with heterosexual sex accounting for almost a quarter of transmissions. Irrespective of geographic region, there is evidence that women can have a different lived experience of HIV due to their unequal social and economic status in society, while MSM can have a different lived experience depending on the laws and customs of their geographic location. Gender differences related to risk factors, stigma, access to services, mental health, health-related quality of life and economic consequences have been consistently reported globally. This paper explores the subjective lived experience of gender and sexuality disparities among three individuals living with HIV in Australia: a male who identified as gay, and a male and female who each identified as heterosexual. Analysis of themes from these three case reports indicated discernible differences by gender and sexuality in four areas: access to medical services, social support, stigma and mental health. It is argued that knowledge and understanding of potential gender and sexuality disparities must be factored into supportive interventions for people living with HIV in Australia.

Antiretroviral treatment adherence and mental disorders: observational case-control study in people living with HIV in Spain

Mental disorders hamper immunological control of HIV infection by exerting a negative influence on antiretroviral therapy (ART) adherence. We sought to address the possible relationship between non-adherence to antiretroviral treatment (ART), mental disorders and substance use in people living with HIV/AIDS (PLWHA) in Spain, which presents a high prevalence of intravenously transmitted HIV infection. We assessed 125 PLWHA attending regular outpatient follow-up. The main adherence measure was pill collection from the Hospital Pharmacy. We included sociodemographic variables, mental disorders diagnosis, and substance use in the 12 months prior to the assessment. Harmful alcohol consumption (OR: 6.834; 95% CI: 2.008-23.257; p = 0.002), suffering from depression (OR: 5.851; 95% CI: 1.470-23.283; p = 0.012) and being at risk of suicide (OR: 3.495; 95% CI: 1.136-10.757; p = 0.029) increased the likelihood of non-adherence. 29.6% of the sample had been infected via blood contact. HCV co-infection was present in 46.4% of the study sample, increasing the likelihood of non-adherence (OR: 3.223; 95% CI: 1.119-9.286; p = 0.030). Harmful alcohol use and some serious mental disorders (especially depression and suicide risk) are consistently associated with non-adherence to ART. HCV co-infection could be an important risk marker of non-adherence among PLWHA with a high prevalence of intravenous drug use.

Psychiatric hospitalization among youth at high risk for HIV

Youth at-risk for HIV are also at-risk for mental health disorders and psychiatric hospitalization. Understanding the association between engagement in HIV prevention, concurrent risk behaviors, and psychiatric hospitalization may lead to improvements in integrated prevention and mental health treatment efforts. Youth at-risk for HIV, aged 14-24 years old, predominantly Black/African American and Latinx (75%) were recruited through youth-serving clinics and community sites in Los Angeles (n = 839) and New Orleans (n = 647). We compared youth with and without histories of psychiatric hospitalization on engagement in HIV prevention, concurrent risk behaviors, and demographic characteristics. We examined predictors of hospitalization using multiple imputations for missing data. Hospitalized youth (30%) were more involved in HIV programs, but were less likely to use PrEP/PEP or condoms than non-hospitalized youth. The odds of hospitalization were higher for transgender/gender nonconforming youth relative to cisgender youth; the OR was increased after adjustment for concurrent risk behaviors. Hospitalization was associated with homelessness, trauma, incarceration, substance use, and involvement in substance abuse treatment programs. There is a continuing need to integrate the diagnosis and treatment of mental health disorders into HIV prevention programs to better address multiple challenges faced by vulnerable youth.

Addressing the Mental and Emotional Health Impacts of COVID-19 on Children and Adolescents: Lessons From HIV/AIDS

The COVID-19 pandemic has led to lasting mental health and psychosocial consequences just as were experienced with the HIV epidemic. A rapid review of published systematic reviews on HIV/AIDS and mental health outcomes and responses among children and adolescents was used to identify lessons for the COVID-19 pandemic response. The review found that HIV/AIDS responses to promote mental health, prevent ill-health and treat mental health conditions included diverse interventions at the structural or national, community, household and individual levels. Some of these responses can be easily replicated, others require substantial adaptation, and some can inform development of new innovative offline and online responses to mitigate impact of COVID-19 on mental health of children and adolescents. Programs that mitigate economic impacts including child grants, income generating activities for caregivers, food distribution, health care vouchers, and other economic empowerment interventions can be replicated with minor adjustments. Helplines for vulnerable or abused children and shelters for victims of gender-based violence can be scaled up to respond to the COVID pandemic, with minimal adaptation to adhere to prevention of contagion. Mass media campaigns to combat stigma and discrimination were successfully employed in the HIV response, and similar interventions could be developed and applied in the COVID context. Some programs will need more substantial adjustments. In health facilities, mainstreaming child-sensitive mental health training of frontline workers and task sharing/shifting to community volunteers and social workers as was done for HIV with community health workers, could advance mental illness detection, particularly among abuse victims, but requires adaptation of protocols. At the community and household levels, expansion of parenting programs can help caregivers navigate negative mental health effects on children, however, these are not often operating at scale, nor well-linked to services. Programs requiring innovation include converting adolescent and youth safe physical spaces into virtual spaces particularly for at-risk girls and young women; organizing virtual community support groups, conversations, and developing online resources. Re-opening of schools and introduction of health and hygiene policies, provides another opportunity for innovation - to provide mental health and psychosocial support to all children as a standard package of care and practice.

Psychiatric Comorbidities in Pediatric Inpatients With Human Immunodeficiency Virus Infection and Impact on Hospital Course: Inputs From a Case-Control Inpatient Study

Objectives In this study, we aimed to delineate psychiatric comorbidities in pediatric inpatients with versus without human immunodeficiency virus (HIV) infection and to measure its impact on the length of stay (LOS) and cost of treatment during hospitalization. Methodology We conducted a case-control study using the Nationwide Inpatient Sample and included 4,920 pediatric inpatients between the ages of six and 18 years who were sub-grouped by a comorbid diagnosis of HIV (N = 2,595) and non-HIV (N = 2,325) and matched for demographics (age, sex, and race) by propensity case-control matching. Logistic regression analyses were used to evaluate the adjusted odds ratio (aOR) of association for psychiatric comorbidities (depression, anxiety, post-traumatic stress disorder, psychosis, and drug abuse) in the HIV-positive compared with the HIV-negative (as reference category) pediatric inpatients. We measured the differences in the LOS and cost using the independent sample t-test. Results We found that the most prevalent psychiatric comorbidities in the HIV-positive group were anxiety (6.9%), drug abuse (6.6%), psychosis (6.4%), and depression (6.2%). The HIV-positive group had a significantly higher likelihood of comorbid psychosis (aOR: 1.82; 95% confidence interval [CI]: 1.38-2.40) and depression (aOR: 1.79; 95% CI: 1.36-2.36). The mean LOS per hospitalization episode was longer for the HIV-positive group (11.1 days vs. 6.0 days; P < 0.001) compared to the HIV-negative pediatric inpatients. Conclusions We found an increased risk of depression by 79% and psychosis by 82% in the HIV-positive pediatric population. These inpatients also had an extended hospitalization stay (by five days), adding to the healthcare economic burden.

Mental Health of Refugees and Migrants during the COVID-19 Pandemic: The Role of Experienced Discrimination and Daily Stressors

The COVID-19 pandemic is a defining global health crisis of our time. While the impact of COVID-19, including its mental health impact, is increasingly being documented, there remain important gaps regarding the specific consequences of the pandemic on particular population groups, including refugees and migrants. This study aims to uncover the impact of the COVID-19 pandemic on the mental health of refugees and migrants worldwide, disentangling the possible role of social and daily stressors, i.e., experiences of discrimination and daily living conditions. Descriptive analysis and structural equation modeling were used to analyze the responses of N = 20,742 refugees and migrants on the self-reporting global ApartTogether survey. Survey findings indicated that the mental health of refugees and migrants during the COVID-19 pandemic was significantly impacted, particularly for certain subgroups, (i.e., insecure housing situation and residence status, older respondents, and females) who reported experiencing higher levels of increased discrimination and increases in daily life stressors. There is a need to recognize the detrimental mental health impact of the COVID-19 pandemic on particular refugee and migrant groups and to develop interventions that target their unique needs.

Mental health symptoms and inflammatory markers among HIV infected patients in Tanzania

Background

HIV and mental disorders are predicted to be the leading causes of illness worldwide by the year 2030. HIV-infected patients are at increased risk of developing mental disorders which are significantly associated with negative clinical outcomes and propagation of new HIV infections. There is little evidence that links inflammation to development of mental disorders among HIV patients. Therefore, the main objective of this study was to evaluate if mental health symptoms were associated with biomarkers of inflammation in HIV infected subjects.

Methods

A cross-sectional study was conducted in Dar es Salam, Tanzania from March to May 2018. Standardized tools were used to collect data based on the World Health Organisation's (WHO) stepwise approach for non-communicable diseases (NCD) surveillance. A total of 407 HIV+ patients on antiretroviral therapy were recruited. The WHO stepwise approach for NCD surveillance was used to collect data together with anthropometric measurements. Mental health symptoms were determined based on self-reported thoughts of helplessness, suicide ideation, depression, despair, discouragement, and feelings of isolation. Enzyme-linked immunosorbent assay was used to test for inflammatory markers:- C-reactive protein (CRP), Iinterleukin-6 (IL-6), interleukin-18 (IL-18), soluble tumour necrosis factor receptor-I (sTNFR-I), and soluble tumour necrosis factor receptor-II (sTNFR-II). Bivariate and multi-variate analysis was conducted to examine the association between biomarkers and mental health symptoms.

Results

The prevalence of self-reported mental health symptoms was 42% (n = 169). Participants with self-reported symptoms of mental health had elevated CRP, were less likely to walk or use a bicycle for at least 10 minutes, were less likely to participate in moderate-intensity sports or fitness activities, and had poor adherence to HIV treatment (p < 0.005). CRP remained significant in the sex adjusted, age-sex adjusted, and age-sex-moderate exercise adjusted models. In the fully adjusted logistic regression model, self-reported mental health symptoms were significantly associated with a higher quartile of elevated CRP (OR 4.4; 95% CI 1.3–5.9) and sTNFR-II (OR 2.6; 95% CI 1.4–6.6) and the third quartile of IL-18 (OR 5.1;95% CI 1.5–17.5) as compared with those reporting no mental health symptoms. The significance of sTNFR-II and IL-18 in the fully adjusted model is confounded by viral load suppression rates at the sixth month.

Conclusion

High CRP and sTNFR II were important contributors to the prevalence of mental health symptoms. This study is among the minimal studies that have examined mental health issues in HIV, and therefore, the findings may offer significant knowledge despite the potential reverse causality. Regardless of the nature of these associations, efforts should be directed toward screening, referral, and follow-up of HIV patients who are at-risk for mental health disorders.

Multimodality assessment of sleep outcomes in people living with HIV performed using validated sleep questionnaires

Studies conducted in people living with HIV (PLHIV) report high rates of sleep disturbance, without a clear explanation as to cause or effect. Therefore, we proposed use of multiple validated questionnaires that would allow a more comprehensive evaluation of sleep quality in PLHIV. We administered eight validated sleep and wellbeing questionnaires, recording different aspects of sleep in order to provide a comprehensive description of sleep quality, quantity, daytime functioning, wakefulness, and general wellbeing. Associations with demographics and clinical data were analyzed by univariable/multivariable analyses. Of 254 subjects 99% were male (98% men who have sex with men), 88% white, mean age 41 (SD ± 9.9) years, HIV duration eight years (SD ± 6.3), 94% were on antiretroviral therapy, mean CD4 cell count was 724 cells/mm³, 81% had HIV RNA<40 copies/ml, 72% were university educated, and 60% used 'chemsex' drugs. Almost half (45%) reported poor sleep quality, 22% insomnia, 21% daytime sleepiness, and 33% fatigue. As individual factors, HIV duration ≥10 years, anxiety, depression, and recreational drug use were associated with poor quality sleep, fatigue, and poorer functional outcomes (p ≤ 0.05). The prevalence of sleep disturbance was high in our cohort of PLHIV. Sleep disturbance was associated with longer duration of HIV infection, depression, anxiety, and recreational drug use.

Correlates of self-reported history of mental health help-seeking: a cross-sectional study among individuals with symptoms of a mental or substance use disorder initiating care for HIV in Cameroon

BACKGROUND

Mental health and substance use disorders (MSDs) increase the risk of poor human immunodeficiency virus (HIV) care outcomes among people living with HIV (PLWH). Receipt of mental health care may improve these adverse outcomes. We aimed to identify correlates of prior mental health help-seeking among PLWH with symptoms of an MSD in Cameroon.

METHODS

We characterize prior mental health help-seeking from formal (mental health specialist/general medical provider) and informal (traditional healer/religious leader) sources among 161 people with symptoms of depression (Patient Health Questionnaire-9 scores> 9), anxiety (General Anxiety Disorder-7 scores> 9), probable post-traumatic stress disorder (PTSD Checklist for DSM-5 scores> 30), or possible alcohol use disorder (Alcohol Use Disorders Identification Test scores≥16) who were newly entering HIV care at three healthcare facilities in Cameroon between June 2019 and March 2020. Help-seeking was defined as ever speaking to a formal or informal source about emotional problems, sadness, or the way they were feeling or behaving. We estimated the association between sociodemographic and psychosocial measures and lifetime mental health help-seeking from each type of source using log-binomial regression.

RESULTS

Overall, 55.3% of 161 PLWH with MSD symptoms reported prior mental health help-seeking, with 24.2% and 46.0% seeking help from formal and informal sources, respectively. Religious leaders were the most common source of help (40.4%), followed by general medical professionals (22.4%), traditional healers (16.8%), and mental health specialists (7.4%). Individuals with higher depressive, anxiety, and trauma symptom severity scores were more likely to have sought help than those with lower scores. Individuals with possible alcohol use disorder were the least likely to have sought help. Prior help-seeking was more common among those reporting a higher number of lifetime traumatic events (prevalence ratio [PR]: 1.06; 95% confidence interval [CI]: 1.01, 1.11) and those with a history of emotional intimate partner violence (PR: 1.34; 95% CI: 1.01, 1.80).

CONCLUSIONS

Prior mental health help-seeking was associated with psychosocial stressors. Help-seeking from informal networks was more common than formal help-seeking. Training in the provision of evidence-based mental health support for informal networks could improve access to mental health care for PLWH with MSDs in Cameroon.

Intervening for HIV prevention and mental health: a review of global literature

INTRODUCTION

Numerous effective HIV prevention options exist, including behaviour change interventions, condom promotion and biomedical interventions, like voluntary medical male circumcision and pre-exposure prophylaxis. However, populations at risk of HIV also face overlapping vulnerabilities to common mental disorders and severe mental illness. Mental health status can affect engagement in HIV risk behaviours and HIV prevention programmes. We conducted a narrative review of the literature on HIV prevention among key populations and other groups vulnerable to HIV infection to understand the relationship between mental health conditions and HIV prevention outcomes and summarize existing evidence on integrated approaches to HIV prevention and mental healthcare.

METHODS

We searched five databases for studies published from January 2015 to August 2020, focused on HIV prevention and mental health conditions among key populations and individuals with serious mental illness. Studies were included if they evaluated an HIV prevention intervention or assessed correlates of HIV risk reduction and included assessment of mental health conditions or a mental health intervention.

RESULTS AND DISCUSSION

We identified 50 studies meeting our inclusion criteria, of which 26 were randomized controlled trials or other experimental designs of an HIV prevention intervention with or without a mental health component. Behaviour change interventions were the most common HIV prevention approach. A majority of studies recruited men who have sex with men and adolescents. Two studies provided distinct approaches to integrated HIV prevention and mental health service delivery. Overall, a majority of included studies showed that symptoms of mental disorder or distress are associated with HIV prevention outcomes (e.g. increased risky sexual behaviour, poor engagement in HIV prevention behaviours). In addition, several studies conducted among groups at high risk of poor mental health found that integrating a mental health component into a behaviour change intervention or linking mental health services to combination prevention activities significantly reduced risk behaviour and mental distress and improved access to mental healthcare.

CONCLUSIONS

Evidence suggests that mental health conditions are associated with poorer HIV prevention outcomes, and tailored integrated approaches are urgently needed to address overlapping vulnerabilities among key populations and other individuals at risk.

Role of Self-Stigma in Pathways from HIV-Related Stigma to Quality of Life Among People Living with HIV

This study examined the relationships between perceived public stigma, experienced stigma, and quality of life in people living with HIV (PLHIV), and whether self-stigma mediates these relationships. Cross-sectional data were analyzed from 1704 PLHIV in care at OLVG hospital in the Netherlands. We measured different types of stigma (perceived public stigma, experienced stigma, and self-stigma), and various quality-of-life outcomes (disclosure concerns, depression, anxiety, sexual problems, sleeping difficulties, self-esteem, general health, and social support). Structural equation modeling was used to test the paths from different types of stigma to quality-of-life outcomes. All direct effects of self-stigma on quality-of-life outcomes were significant. The final mediation model showed that the effects of both perceived public and experienced stigma on quality-of-life outcomes were mediated by self-stigma. These findings highlight the importance of addressing self-stigma in PLHIV, and call for (psychosocial) interventions that reduce the harmful effects of HIV-related stigma.

Measuring Unmet Needs among Persons Living with HIV at Different Stages of the Care Continuum

Unmet needs can impede optimal care engagement, impacting the health and well-being of people living with HIV (PLWH); yet, whether unmet needs differ by care engagement status is not well understood. Using surveys and qualitative interviews, we examined and compared unmet needs for PLWH (n = 172) at different levels of care engagement. Unmet needs varied only slightly by care status. Survey findings revealed that provision of housing, emergency financial assistance, employment assistance, and food security were the greatest unmet need; for those in care, housing was the greatest unmet need, whereas for those sporadically in care or out of care, employment assistance was the greatest unmet needs. Qualitative interviews likewise illustrated that a lack of financial resources including insurance, housing, employment, and transportation presented barriers to care engagement across all care groups. Our findings indicate that unmet needs among PLWH are complex and multi-faceted across care engagement status.

Factors associated with external HIV-related stigma and psychological distress among people living with HIV in South Africa

BACKGROUND

HIV-related stigma and psychological distress among people living with HIV (PLHIV) pose a public health challenge in most African countries. This study aims to investigate the association between HIV-related stigmatizing attitudes and psychological distress amongst PLHIV in South Africa using the 2012 nationally representative population-based household survey.

METHODS

The data used in the analysis were collected using a multi-stage stratified cluster sampling design. Bivariate and multivariate logistic regression models were used to identify factors associated with stigma among PLHIV with psychological distress. A total of 2521 HIV positive individuals that responded to the question on psychological distress, 34.3% had psychological distress and 37.9% experienced high levels of HIV related stigmatizing attitudes. Stigmatizing attitudes among PLHIV with psychological distress were significantly less likely among those with secondary level education [aOR = 0.67 (95% CI: 0.44-1.01), p = 0.050], those with correct knowledge about HIV and rejection of myths about HIV [aOR = 0.58 (95% CI: 0.38-0.89), p = 0.013], and those who ever tested for HIV [aOR = 0.65 (95% CI: 0.42-1.01), p = 0.054].

CONCLUSION

The findings suggest a need to reinvigorate stigma-reduction interventions in the national HIV response with emphasis on HIV awareness and education campaigns. In addition, HIV testing services should be reinforced through communication strategies targeted against HIV stigmatization, discrimination and fear. There is also a need to continuously engage PLHIV in programs through counselling and support interventions for acceptance of HIV positive status and to help them cope with HIV-related stigma.

Interventions to address the mental health of adolescents and young adults living with or affected by HIV: state of the evidence

INTRODUCTION

Adolescents and young adults (AYA) remain vulnerable to HIV-infection and significant co-morbid mental health challenges that are barriers to treatment and prevention efforts. Globally millions of AYA are living with HIV (AYALH) and/or have been affected by HIV in their families (AYAAH), with studies highlighting the need for mental health programmes. With no current guidelines for delivering mental health interventions for AYALH or AYAAH, a scoping review was undertaken to explore current evidence-based mental health interventions for AYALH and AYAAH to inform future work.

METHODS

The review, targeting work between 2014 and 2020, initially included studies of evidence-based mental health interventions for AYALH and AYAAH, ages 10 to 24 years, that used traditional mental health treatments. Given the few studies identified, we expanded our search to include psychosocial interventions that had mental health study outcomes.

RESULTS AND DISCUSSION

We identified 13 studies, seven focused on AYALH, five on AYAAH, and one on both. Most studies took place in sub-Saharan Africa. Depression was targeted in eight studies with the remainder focused on a range of emotional and behavioural symptoms. Few studies used evidence-based approaches such as Cognitive Behaviour Therapy; psychosocial approaches included mental health treatments, group-based and family strengthening interventions, economic empowerment combined with family strengthening, group-based mindfulness and community interventions. Eleven studies were randomized control trials with four pilot studies. There was variation in sample size, treatment delivery mode (individual focus, group-based, family focus), and measures of effectiveness across studies. Most used trained lay counsellors as facilitators, with few using trained mental health professionals. Eleven studies reported positive intervention effects on mental health.

CONCLUSIONS

Despite the need for mental health interventions for AYALH and AYAAH, we know surprisingly little about mental health treatment for this vulnerable population. There are some promising approaches, but more work is needed to identify evidence-based approaches and corresponding mechanisms of change. Given limited resources, integrating mental health treatment into healthcare settings and using digital health approaches may support more standardized and scalable treatments. Greater emphasis on implementation science frameworks is needed to create sustainable mental health treatment for AYALH and AYAAH globally.

Mental health interventions for persons living with HIV in low- and middle-income countries: a systematic review

INTRODUCTION

Addressing the intersection between mental health and HIV is critical for the wellbeing of persons living with HIV (PLWH). This systematic review synthesized the literature on mental health interventions for PLWH in low- and middle-income countries (LMICs) to determine intervention components and explore their relationship with intervention effectiveness.

METHODS

We included only controlled clinical trials of interventions aiming to improve the mental health of PLWH. We conducted a search in the following databases: PubMed, CINAHL, PsycINFO and EMBASE for eligible studies describing the evaluation of interventions for mental health problems among PLWH in LMICs published through August 2020. Two reviewers independently screened references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria.

RESULTS

We identified a total of 30 eligible articles representing 6477 PLWH who were assigned to either the intervention arm (n = 3182) or control arm (n = 3346). The mental health interventions evaluated were psychological (n = 17, 56.67%), pharmacological (n = 6, 20.00%), combined psychological and pharmacological (n = 1, 3.33%) and complementary/alternative treatments (n = 6, 20.00%). The mental health problems targeted were depression (n = 22, 73.33 %), multiple psychological symptoms (n = 1, 3.33%), alcohol and substance use problems (n = 4, 13.33%), post-traumatic stress disorder (n = 1, 3.33%) and HIV-related neuro-cognitive impairment (n = 2, 6.67%). Studies of interventions with significant effects had significantly a higher number of active ingredients than those without significant effects [3.41 (2.24) vs. 1.84 (1.46) Mean (SD)] [Mean difference = -1.56, 95% CI = -3.03 to -0.09, p = 0.037].

CONCLUSIONS

There continue to be advances in mental health interventions for PLWH with mental illness in LMICs. However, more research is needed to elucidate how intervention components lead to intervention effectiveness. We recommend scale up of culturally appropriate interventions that have been successfully evaluated in low- and middle-income countries.

Multilevel factors associated with anxiety symptoms among people living with HIV in the US South

People living with HIV are more likely than people not living with HIV to experience Generalized Anxiety Disorder (GAD) Symptoms. Scholars have found that 19%-23% of people living with HIV experience GAD Symptoms. Current studies overwhelmingly examine individual factors among national samples and are not conducted in the US South, where HIV rates have increased significantly in recent years. Even fewer studies examine the multilevel factors that are associated with anxiety in this US South. Thus, this study examined the multilevel factors associated with anxiety symptoms in a large US Southern City. A multivariate linear regression was conducted to examine multilevel factors associated with anxiety symptoms among 111 people living with HIV. Two structural variables, housing satisfaction and mental health service needs and one intrapersonal variable, health quality of life, were significantly associated with symptoms of anxiety. The study points to the needs of focusing multilevel interventions not only on housing conditions, but also attention to participants' satisfaction of their housing.

Assessing psychological symptom networks related to HIV-positive duration among people living with HIV: a network analysis

This study aims to explore and visualize relationships among multiple psychological symptoms among people living with HIV (PLWH) with different HIV-positive durations and to compare centrality indices and densities of psychological symptom networks. We used subsets of data collected from five designated HIV/AIDS hospitals in China. Networks were constructed among 16 psychological symptoms. Centrality properties, including strength and closeness, were adopted to describe relationships among symptoms. The results showed that PLWH with longer HIV-positive durations had denser emotional networks, which indicated that they had more emotional neuroticism than their newly diagnosed counterparts. Sadness, self-abasement, and self-loathing were the most central psychological symptoms across different HIV-positive durations. Our study suggests the need to provide psychosocial support services targeting PLWH according to changing symptom severity and neuroticism trajectories. Interventions should focus on increasing empathy for PLWH and enhancing the ability to consider the situation from different perspectives to avoid the development of neuroticism in long-term survivors.

Interventions Addressing Depression and HIV-Related Outcomes in People with HIV

PURPOSE OF REVIEW

People with HIV (PWH) are more likely to experience depression than those without HIV. Depression is not only distressing and interfering in and of itself, but it is also consistently associated with non-adherence to antiretroviral treatment (ART). Accordingly, research and clinical priorities require updated knowledge about interventions that address depression in PWH.

RECENT FINDINGS

Twenty efficacy trials and nine pilot studies since a 2009 review emerged in the literature review search. Of these, 11 and 6 respectively had a depression-related inclusion criterion. The intervention strategies included individual psychotherapy (n=6), group therapy (n=6), telehealth (n=3), and antidepressant medication (n=5). Generally, these interventions demonstrated acute efficacy for improving depression symptoms in PWH, with some also addressing ART non-adherence. However, not all studies collected follow-up data. Furthermore, trials that addressed depression but did not specifically address non-adherence did not also show adherence improvements. Existing interventions for depression have demonstrated efficacy in PWH, and these may have both positive mental and physical health outcomes. Future trials should measure and boost longer-term effects. It would be useful to incorporate adherence interventions into depression treatment to improve self-care behaviors and health outcomes.

The treatment gap for mental disorders in adults enrolled in HIV treatment programmes in South Africa: a cohort study using linked electronic health records

AIMS

Mental disorders are common in people living with HIV (PLWH) but often remain untreated. This study aimed to explore the treatment gap for mental disorders in adults followed-up in antiretroviral therapy (ART) programmes in South Africa and disparities between ART programmes regarding the provision of mental health services.

METHODS

We conducted a cohort study using ART programme data and linked pharmacy and hospitalisation data to examine the 12-month prevalence of treatment for mental disorders and factors associated with the rate of treatment for mental disorders among adults, aged 15-49 years, followed-up from 1 January 2012 to 31 December 2017 at one private care, one public tertiary care and two pubic primary care ART programmes in South Africa. We calculated the treatment gap for mental disorders as the discrepancy between the 12-month prevalence of mental disorders in PLWH (aged 15-49 years) in South Africa (estimated based on data from the Global Burden of Disease study) and the 12-month prevalence of treatment for mental disorders in ART programmes. We calculated adjusted rate ratios (aRRs) for factors associated with the treatment rate of mental disorders using Poisson regression.

RESULTS

In total, 182 285 ART patients were followed-up over 405 153 person-years. In 2017, the estimated treatment gap for mental disorders was 40.5% (95% confidence interval [CI] 19.5-52.9) for patients followed-up in private care, 96.5% (95% CI 95.0-97.5) for patients followed-up in public primary care and 65.0% (95% CI 36.5-85.1) for patients followed-up in public tertiary care ART programmes. Rates of treatment with antidepressants, anxiolytics and antipsychotics were 17 (aRR 0.06, 95% CI 0.06-0.07), 50 (aRR 0.02, 95% CI 0.01-0.03) and 2.6 (aRR 0.39, 95% CI 0.35-0.43) times lower in public primary care programmes than in the private sector programmes.

CONCLUSIONS

There is a large treatment gap for mental disorders in PLWH in South Africa and substantial disparities in access to mental health services between patients receiving ART in the public vs the private sector. In the public sector and especially in public primary care, PLWH with common mental disorders remain mostly untreated.

Longitudinal Bidirectional Relations among Parenting Quality, Parenting Stress, and Child Functioning in HIV-affected Families

Mothers living with HIV (MLH) face unique stressors impacting parenting, parenting stress, and child psychosocial functioning, but longitudinal, bidirectional relations among family processes have not been examined in this population. This study examined relations among parenting quality, parenting stress, and child functioning in 174 MLH-child dyads (aged 6-14, M_age = 9.65, SD = 2.49; 51% female; 57% Black/African American; 35% Latinx). Families completed self-report questionnaires over four waves spanning 15 months. Cross-lagged panel analysis revealed unidirectional and bidirectional relations between parenting stress and child functioning; parenting quality and child functioning; and parenting quality and parenting stress. The findings suggest that prevention and intervention efforts with HIV-affected families should target both parent factors (e.g., communication skills) and child factors (e.g., emotion regulation), emphasizing parenting stress reduction in order to bolster family outcomes.

Evaluating potential mediators for the impact of a family-based economic intervention (Suubi+Adherence) on the mental health of adolescents living with HIV in Uganda

INTRODUCTION

Many adolescents living with HIV in sub-Saharan Africa (SSA) experience poverty and have access to limited resources, which can impact HIV and mental health outcomes. Few studies have analyzed the impact of economic empowerment interventions on the psychosocial wellbeing of adolescents living with HIV in low resource communities, and this study aims to examine the mediating mechanism(s) that may explain the relationship between a family economic empowerment intervention (Suubi + Adherence) and mental health outcomes for adolescents (ages 10-16 at enrollment) living with HIV in Uganda.

METHOD

We utilized data from Suubi + Adherence, a large-scale six-year (2012-2018) longitudinal randomized controlled trial (N = 702). Generalized structural equation models (GSEMs) were conducted to examine 6 potential mediators (HIV viral suppression, food security, family assets, and employment, HIV stigma, HIV status disclosure comfort level, and family cohesion) to determine those that may have driven the effects of the Suubi + Adherence intervention on adolescents' mental health.

RESULTS

Family assets and employment were the only statistically significant mediators during follow-up (β from -0.03 to -0.06), indicating that the intervention improved family assets and employment which, in turn, was associated with improved mental health. The proportion of the total effect mediated by family assets and employment was from 42.26% to 71.94%.

CONCLUSIONS

Given that mental health services provision is inadequate in SSA, effective interventions incorporating components related to family assets, employment, and financial stability are crucial to supporting the mental health needs of adolescents living with HIV in under-resourced countries like Uganda. Future research should work to develop the sustainability of such interventions to improve long-term mental health outcomes among this at-risk group.

The Pre-exposure Prophylaxis (PrEP) Care Cascade in People Who Inject Drugs: A Systematic Review

Injection drug use is a key risk factor for the transmission of HIV. Prevention strategies, such as the use of pre-exposure prophylaxis (PrEP), are effective at reducing the risk of HIV transmission in people who inject drugs (PWID). Following PRISMA guidelines, a literature search was conducted to identify the current state of the PrEP care cascade in PWID. Twenty-three articles were evaluated in this systematic review. A decline in engagement throughout the stages of the PrEP care cascade was found. High awareness and willingness to use PrEP was found, yet PrEP uptake was relatively low (0-3%). There is a lack of research on interventions to increase engagement of PrEP across all levels of the care cascade in PWID. Implications from the interventions that have been published provide insight into practice and public policy on efficacious strategies to reduce HIV incidence in PWID. Our findings suggest that more efforts are needed to identify and screen PWID for PrEP eligibility and to link and maintain them with appropriate PrEP care.

Psychosocial Factors Associated with Suicidal Ideation Among HIV/AIDS Patients on Follow-Up at Dessie Referral Hospital, Northeast Ethiopia: A Cross-Sectional Study

Background

Psychosocial and mental health problems are common among HIV/AIDS patients that affect sustained utilization of healthcare services. To date, information is scarce regarding the perceived stigma, level of social support, and suicidal ideation among HIV/AIDS patients in the study setting. Therefore, this study aimed to assess psychosocial factors associated with suicidal ideation among HIV/AIDS patients on follow-up in the study setting.

Methods

A hospital-based cross-sectional study was conducted among people living with HIV/AIDS (PLWH) on antiretroviral therapy follow-up for at least six months at a referral hospital in northeastern Ethiopia from November to January 2019. A total of 395 study participants of antiretroviral therapy clinic visitors were selected systematically. A binary logistic regression model was fitted to identify factors associated with suicidal ideation among PLWH. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and variables having less than or equal 0.05 p-value used to declare statistical significant association.

Results

This study revealed that 45.3%, 56.5%, and 20%, had perceived stigma, poor social support, and depression, respectively. Moreover, the prevalence of suicidal ideation was 9.4% (95% CI: 6.7 to 12.7) of which, 3.3% had attempted to kill themselves. Low body mass index (AOR=4.11, 95% CI: 1.70 9.91), stages three and above illnesses (AOR=6.63, 95% CI: 1.30 33.79), depression (AOR=4.67, 95% CI: 4.67, 95% CI: 1.75 3.93), poor social support (AOR=4.18, 95% CI: 1.46 11.94), and fair and poor adherence (AOR=3.51, 95% CI: 1.14 10.85) were factors associated with suicidal ideation among PLWH.

Conclusion

This study showed that mental disorders and psychosocial problems were common among PLWH. The poor social support, depression, low body mass index, and poor adherence to ART medications were factors associated with suicidal ideation. This finding underscores the importance of regular screening for common mental health disorders and the strengthening of counseling services, nutritional, and psychosocial support programs.

Alleviating psychological distress and promoting mental wellbeing among adolescents living with HIV in sub-Saharan Africa, during and after COVID-19

COVID-19 social control measures (e.g. physical distancing and lockdowns) can have both immediate (social isolation, loneliness, anxiety, stress) and long-term effects (depression, post-traumatic stress disorder) on individuals' mental health. This may be particularly true of adolescents living with HIV (ALHIV) and their caregivers - populations already overburdened by intersecting stressors (e.g. psychosocial, biomedical, familial, economic, social, or environmental). Addressing the adverse mental health sequelae of COVID-19 among ALHIV requires a multi-dimensional approach that at once (a) economically empowers ALHIV and their households and (b) trains, mentors, and supervises community members as lay mental health services providers. Mental health literacy programming can also be implemented to increase mental health knowledge, reduce stigma, and improve service use among ALHIV. Schools and HIV care clinics offer ideal environments for increasing mental health literacy and improving access to mental health services.

Not Enough Money and Too Many Thoughts: Exploring Perceptions of Mental Health in Two Ugandan Districts Through the Mental Health Literacy Framework

Mental health disorders account for a heavy disease burden in Uganda. In order to provide culturally appropriate mental health prevention and treatment approaches, it is necessary to understand how mental health is conceptualized in the population. Three focus group discussions (FGDs) and 31 in-depth interviews (IDIs) were conducted with men and women aged 14 to 62 years residing in rural, urban, and semi-urban low-income communities in central and western Uganda to explore perceptions and knowledge of mental health. Interpretive thematic analysis was undertaken; results were organized through the lens of the mental health literacy framework. Environmental and societal stressors were identified as primary underlying causes of poor mental health. While participants recognized symptoms of poor mental health, gaps in mental health literacy also emerged. Mental health resources are needed in this setting and additional qualitative work assessing knowledge and attitudes toward mental health care seeking behavior can inform the development of acceptable integrated services.

Undetectable viral load and HIV transmission dynamics on an individual and population level: where next in the global HIV response?

PURPOSE OF REVIEW

To examine recent literature on the efficacy and effectiveness of HIV treatment in preventing HIV transmission through sexual exposure, at both an individual and at a population level.

RECENT FINDINGS

Two recent studies on the individual-level efficacy of treatment as prevention (TasP) have added to the now conclusive evidence that HIV cannot be transmitted sexually when the virus is suppressed. However, four large cluster-randomized population-level trials on universal HIV testing and treatment in Africa have not delivered the expected impact in reducing HIV incidence at a population level. Two of these trials showed no differences in HIV incidence between the intervention and control arms, one demonstrated a nonsignificant lower incidence in the intervention arm, and the fourth trial found a reduction between the communities receiving a combination prevention package and the control arm, but no difference between the immediate treatment plus the prevention package and the control arm. Factors contributing to the disconnect between individual high-level efficacy and population-level effectiveness of TasP include undiagnosed infection, delays in linkage to care, challenges in retention and adherence to antiretroviral therapy (ART), time between ART initiation and viral suppression, and stigma and discrimination.

SUMMARY

Suppressive ART renders people living with HIV sexually noninfectious. However, epidemic control is unlikely to be achieved by TasP alone.

Perceived Positive Consequences Are Associated with Unhealthy Alcohol Use Among Persons Living with HIV

Background

Understanding how perceived positive consequences are associated with drinking may help improve effectiveness of alcohol reduction interventions among people living with HIV (PLWH). We aimed to determine whether perceived positive consequence scores varied by sociodemographic, drinking, mental health or substance use variables.

Methods

Perceived positive consequences of drinking were assessed using the PROMIS: Positive Consequences-Short Form. Unhealthy alcohol use was measured using a modified AUDIT-C. We used multiple linear regression to identify factors associated with perceived positive consequence.

Results

328 PLWH who consumed at least one alcoholic beverage in the last 6 months participated in the Florida Cohort study (mean age=46, 69% male, 58% Black). Perceived positive consequence scores ranged from 0 to 28 (mean=16.1, SD=6.9). Perceived positive consequence scores increased by 0.8 points for each 1-point increase in AUDIT-C score. Demographics, thoughts on reducing alcohol use, other substance use, depression, and anxiety were not significantly associated with perceived positive consequences.

Conclusions

Our findings suggest perceived positive consequences are associated with unhealthy alcohol use. Positive consequences should be considered with negative consequences in a decisional balance when intervening on alcohol use among PLWH.

An Emerging Syndemic of Smoking and Cardiopulmonary Diseases in People Living with HIV in Africa

Background: African countries have the highest number of people living with HIV (PWH). The continent is home to 12% of the global population, but accounts for 71% of PWH globally. Antiretroviral therapy has played an important role in the reduction of the morbidity and mortality rates for HIV, which necessitates increased surveillance of the threats from pernicious risks to which PWH who live longer remain exposed. This includes cardiopulmonary comorbidities, which pose significant public health and economic challenges. A significant contributor to the cardiopulmonary comorbidities is tobacco smoking. Indeed, globally, PWH have a 2–4-fold higher utilization of tobacco compared to the general population, leading to endothelial dysfunction and atherogenesis that result in cardiopulmonary diseases, such as chronic obstructive pulmonary disease and coronary artery disease. In the context of PWH, we discuss (1) the current trends in cigarette smoking and (2) the lack of geographically relevant data on the cardiopulmonary conditions associated with smoking; we then review (3) the current evidence on chronic inflammation induced by smoking and the potential pathways for cardiopulmonary disease and (4) the multifactorial nature of the syndemic of smoking, HIV, and cardiopulmonary diseases. This commentary calls for a major, multi-setting cohort study using a syndemics framework to assess cardiopulmonary disease outcomes among PWH who smoke. Conclusion: We call for a parallel program of implementation research to promote the adoption of evidence-based interventions, which could improve health outcomes for PWH with cardiopulmonary diseases and address the health inequities experienced by PWH in African countries.

Perinatal depressive symptoms and breastfeeding behaviors: A systematic literature review and biosocial research agenda

BACKGROUND

Breastfeeding is recommended to improve maternal and infant health globally. Depression has been posited to negatively impact breastfeeding, although potential causal and bidirectional pathways between these two phenomena have not been sufficiently characterized. We therefore conducted a systematic review to critically evaluate available evidence on the relationship between perinatal depressive symptoms and breastfeeding behaviors; to identify knowledge gaps and propose a biosocial research agenda to advance our understanding of this topic.

METHODS

A systematic search strategy was applied across seven databases. Data were extracted and aggregated using the matrix method to provide a narrative synthesis of findings.

RESULTS

Thirty-eight studies from 20 countries spanning 1988 through 2018 fit the inclusion criteria. In general, methods across studies were heterogeneous. Fourteen different tools were used to measure perinatal depressive symptoms. Nearly half the studies did not provide breastfeeding definitions. No studies from low-income countries met inclusion criteria. More than half (63%) of studies demonstrated a negative association between depressive symptoms across the perinatal period and less exclusive breastfeeding and/or shorter breastfeeding durations.

LIMITATIONS

Heterogeneity in study design, definitions, assessment tools, and measurement time points limited the comparability of study findings. Causality cannot be assessed.

CONCLUSIONS

Available evidence suggests perinatal depressive symptoms negatively associated with breastfeeding exclusivity and duration, which can lead to suboptimal infant nutrition and detrimental impacts on maternal mental and physical health. To better understand this relationship, we propose including consistent operationalization and assessment of depression and breastfeeding globally and concurrent repeated measures of key biological and social factors.

Mental Health and Perceived Access to Care among People Who Inject Drugs in Athens, Greece

Poor mental health among human immunodeficiency virus (HIV)-positive people who inject drugs (PWID) may contribute to stigma, and together they act as barriers to medical care. This analysis aims to examine factors associated with the mental health of PWID and their network contacts, and the association of poor mental health with the experience of HIV-related stigmatizing events, with HIV-related social support, and with perceived access to care. Data were collected during the Transmission Reduction Intervention Project (TRIP) conducted in Athens, Greece (2013-2015). PWID (n = 292; n = 122 HIV-positive) were interviewed both at baseline and follow-up. Items of depression, anxiety, and general positive affect subscales of the Mental Health Inventory were used to explore the psychological distress and well-being of participants at follow-up. Items of the Access to Care Scale were used to evaluate perceived access to medical care at baseline and follow-up. Linear regression showed that unemployment was positively related to depression (β = 1.49, p = 0.019), while injecting drug use was a risk factor for a low general positive affect score (β = -3.21, p = 0.015). Poor mental health was not linked to HIV-related stigma or social support. Positive perception of access to care was associated in multivariable analyses with low depression (β = -0.22, p = 0.049). The perceived access to care score improved from baseline to follow-up (p = 0.019) and HIV-positive participants had a higher score than HIV-negative participants. Future interventions should include targets to improve the mental well-being of participants, reduce psychosocial distress, and minimize perceived barriers to accessing medical care.