Cumulative Psychosocial Risk is a Salient Predictor of Depressive Symptoms among Vertically HIV-Infected and HIV-Affected Adolescents at the Kenyan Coast

In utero/peripartum antiretroviral therapy exposure and mental health outcomes at 8-18 years old: A longitudinal comparative study of children with perinatally acquired HIV, children perinatally HIV exposed but uninfected, and children unexposed uninfected from Uganda

In utero/peripartum antiretroviral therapy (IPA) exposure type was examined in relationship to mental health symptoms among 577 children with perinatally acquired HIV (CPHIV), children perinatally HIV exposed but uninfected (CHEU), and children HIV unexposed uninfected (CHUU). IPA exposure was categorized for CPHIV and CHEU as none, single-dose nevirapine with or without zidovudine (sdNVP±AZT), sdNVP+AZT+lamivudine (3TC), or combination antiretroviral therapy (cART). Anxiety and depressive symptoms were reported at baseline, 6-, and 12-month follow-up per behavioral assessment system for children. Multivariable linear mixed models were used to estimate differences (b) with 95% confidence intervals (95% CI) for IPA exposure types versus CHEU without IPA exposure. Depressive and anxiety symptoms were lower in CHUU relative to CHEU and CPHIV but did not differ between CPHIV and CHEU. CHEU with sdNVP±AZT exposure had greater anxiety (b = 0.51, 95% CI: [0.06, 0.96]) and depressive symptoms (b = 0.48, 95% CI: [0.07, 0.89]) than CHEU without IPA exposure. CHEU with sdNVP+AZT+3TC exposure had higher anxiety (b = 0.0.45, 95% CI: [0.03, 0.86]) and depressive symptoms (b = 0.72, 95% CI: [0.27, 1.17]) versus CHEU without IPA exposure. Depressive and anxiety symptoms were not different for CHEU and CPHIV exposed to cART (b = 0.12-0.60, 95% CI: [-0.41, 1.30]) and CHEU and CHUU (b = -0.04 to 0.08, 95% CI: [-0.24, 0.29]) without IPA exposure. Among CHEU, peripartum sdNVP±AZT and sdNVP+AZT+3TC but not cART compared to no IPA exposure was associated with clinically important elevations in anxiety and depressive symptoms. Monitoring of mental health trajectory of HIV-affected children considering IPA is needed to inform mental health interventions. Patient Contribution: Caregivers and their dependents provided consent for participation and collaborated with study team to identify mutually convenient times for protocol implementation.

A qualitative inquiry of experiences of HIV-related stigma and its effects among people living with HIV on treatment in rural Kilifi, Kenya

Background

The pervasiveness of HIV-related stigma and discrimination, and its consequences on HIV prevention and treatment, have been well documented. However, little is known about the lived experiences of HIV-related stigma and its effects among the general adult population living with HIV in rural African settings. This study set out to explore this knowledge gap.

Methods

From April to June 2018, we conducted in-depth interviews with a convenience sample of 40 adults living with HIV aged 18-58 years in Kilifi, Kenya. A semi-structured interview guide was used to explore experiences of HIV-related stigma and its impact on these adults. A framework approach was used to analyze the data using NVIVO 11 software.

Results

Participants reported experiences of HIV-related stigma in its various forms (anticipated, perceived, internalised, and enacted), as well as its effects on HIV treatment and social and personal spheres. The internalisation of stigma caused by enacted stigma impacted care-seeking behavior resulting in worse overall health. Anxiety and depression characterized by suicidal ideation were the results of internalised stigma. Anticipated stigma prompted HIV medication concealment, care-seeking in remote healthcare facilities, and care avoidance. Fewer social interactions and marital conflicts resulted from perceived stigma. Overall, HIV-related stigma resulted in partial and non-disclosure of HIV seropositivity and medication non-adherence. At a personal level, mental health issues and diminished sexual or marital prospects (for the unmarried) were reported.

Conclusion

Despite high awareness of HIV and AIDS among the general population in Kenya, adults living with HIV in rural Kilifi still experience different forms of HIV-related stigma (including self-stigma) that result in a raft of social, personal, and HIV-treatment-related consequences. Our findings underscore the urgent need to reevaluate and adopt more effective strategies for implementing HIV-related anti-stigma programs at the community level. Addressing individual-level stigma will require the design of targeted interventions. To improve the lives of adults living with HIV in Kilifi, the effects of HIV-related stigma, particularly on HIV treatment, must be addressed.

Mental Health Problems Across the HIV Care Continuum for Adolescents Living with HIV in Sub-Saharan Africa: A Scoping Review

Mental health problems (e.g., anxiety, depression) are frequently experienced by adolescents living with HIV (ALWH) and can worsen HIV-related outcomes. This scoping review synthesizes the existing research on ALWHs' mental health problems at multiple steps along the HIV care continuum in sub-Saharan Africa. Searching PubMed, CINAHL, EMBASE, and PsycINFO identified 34 peer-reviewed studies that met inclusion criteria. Most studies assessed ALWHs' mental health problems at the "Engaged or Retained in Care" continuum step, are cross-sectional, focus on depression and anxiety, and used measures developed in high-income countries. Studies identify mental health problems among ALWH as prevalent and barriers to care. Significant gaps remain in understanding how mental health problems and their relationships with HIV-related health outcomes shift across the continuum. Additional attention is needed, especially at the HIV testing and viral suppression steps, to generate a more comprehensive understanding of mental health needs and priority timepoints for intervention for ALWH.

Correlates of health-related quality of life in primary caregivers of perinatally HIV infected and HIV exposed uninfected adolescents at the Kenyan Coast

BACKGROUND

Mothers and other primary caregivers play a crucial role in looking after perinatally HIV infected, and HIV exposed uninfected adolescents in sub-Saharan Africa. Day- to-day caregiving in the context of limited instrumental support and added biomedical risk (HIV seropositivity) may expose these caregivers to adverse states of health. Unfortunately, very few studies have examined their health-related quality of life (HRQoL). Our study documents the HRQoL profile, and associated factors in primary caregivers of perinatally HIV infected, perinatally HIV exposed but uninfected and HIV unexposed/uninfected adolescents aged 12-17 years at the Kenyan Coast.

METHODS

This was a cross-sectional analysis of 485 primary caregivers: 195 of perinatally HIV infected adolescents, 128 of perinatally HIV exposed but uninfected adolescents and 162 of HIV unexposed/uninfected adolescents. All caregivers completed a self-report measure of HRQoL (having 8 subscales), depressive symptoms, and parenting stress. They also provided their sociodemographic information and that of the care recipients. We used one-way analysis of variance to assess statistical differences among the groups. Linear regression analyses were used to identify correlates of HRQoL.

RESULTS

Overall, caregivers of HIV unexposed/uninfected adolescents reported significantly higher mean HRQoL scores than the other caregivers in the overall HRQoL domain and majority of the subscales. There were no statistical differences in the overall HRQoL scores and most subscales between caregivers of HIV exposed adolescents. Linear regression analyses across the sample indicated that depressive symptoms, increasing age of caregiver, and caring for an adolescent perinatally exposed to HIV were significantly associated with reduced HRQoL at both the overall and sub-scale level. Having a professional job relative to subsistence farming was the only factor associated with improved overall HRQoL. At subscale level, higher socioeconomic status correlated positively with HRQoL while being a grandparent, level of education, parenting stress were negatively associated with HRQoL.

CONCLUSIONS

Caregivers in this sample, especially those who are ageing, at risk of mental ill-health, and taking care of adolescents perinatally exposed to HIV, appear to be vulnerable to poor quality of life. Inclusive and multi-component interventions tailored to the caregivers' psychosocial and mental needs will potentially enhance their quality of life.

Psychiatric Disorders in Adolescents Living with HIV and Association with Antiretroviral Therapy Adherence in Sub-Saharan Africa: A Systematic Review and Meta-analysis

In sub-Saharan Africa (SSA), a systematic approach to exploring the prevalence of psychiatric disorders (PDs) and adherence to antiretroviral treatment (ART) in adolescents living with HIV (ALWHIV) is lacking. This study aimed to systematically review the studies conducted in SSA on the prevalence of PDs among ALWHIV and their association with ART adherence. A systematic search of all English studies assessing PDs among ALWHIV using the Web of Science, PubMed, and EBSCO databases was conducted between March 1 and September 30, 2019. Forty-two studies published between 2009 to 2019 met the inclusion criteria, of which 15 were included in the meta-analysis. The most common PDs were depression (0.24, 95% CI 0.14-0.36) and anxiety disorder (0.26, 95% CI 2-0.44). The available evidence could not conclude on the definitive association between PDs and ART adherence; therefore, further research is required. However, the need for mental health integration in the care for ALWHIV is evident.

Prevalence and factors associated with common mental disorders in young people living with HIV in sub-Saharan Africa: a systematic review

INTRODUCTION

Common mental disorders (CMDs) particularly depression and anxiety, are highly comorbid with HIV also in young people living with HIV (YLWH). In sub-Saharan Africa (SSA) where most YLWH reside, there are limited summary data on CMDs among these youths, yet there are previous systematic reviews summarizing data on CMDs among adults living with HIV. We conducted a systematic literature review on the prevalence and correlates of CMDs among YLWH, aged 10 to 24 years, from SSA.

METHODS

We searched African Index Medicus, African Journals Online and five other electronic databases (from database inception up to 31 December 2020) for relevant studies published in English. The key search terms applied were as follows: "Depression OR Anxiety", "Young people", "HIV infections" and "sub-Saharan Africa".

RESULTS AND DISCUSSION

Out of 3989 articles, 31 studies were included in the review. The prevalence of CMDs in YLWH widely varied ranging between 16.0% and 40.8% for major depression, 4.4% and 52.6% for depressive symptoms and 2.2% and 25.0% for anxiety symptoms. Anxiety disorder was estimated at 45.6%. Four of the five included studies with a comparison group of HIV-negative young people reported significantly higher prevalence estimates of depressive disorders among YLWH. Several sociodemographic, psychosocial and HIV-related correlates of CMDs were reported but most lacked consensus across studies. Nevertheless, female sex, older age, fewer schooling years, HIV-positive status, bullying, sexual abuse, HIV-related stigma, social support and poor antiretroviral therapy adherence were frequently reported (in ≥2 studies) as significant correlates of depressive symptoms among YLWH. Higher social support was the only frequent significant correlate of anxiety symptoms.

CONCLUSIONS

The burden of CMDs among YLWH from SSA is substantial and appears to be significantly higher when compared with HIV-negative peers, particularly for depressive disorders. However, more comparative research is needed. Importantly, screening for CMDs at the youth HIV-clinics should be prioritized especially for YLWH at high risk of CMDs, to facilitate early management or referral for treatment. Furthermore, youth-friendly psychological interventions addressing CMDs in YLWH should urgently be piloted in SSA, incorporating contextual components that may directly or indirectly reduce symptoms of CMDs among YLWH, such as social support.

Childhood trauma, major depressive disorder, suicidality, and the modifying role of social support among adolescents living with HIV in rural Uganda

BACKGROUND

Childhood trauma is associated with mental health problems among adolescents living with HIV (ALHIV) in sub-Saharan Africa, but little is known about potential moderating factors.

METHODS

We enrolled 224 ALHIV aged 13-17 years and collected information on childhood trauma, major depressive disorder, and suicidality. We used modified multivariable Poisson regression to estimate the association between the mental health outcome variables and childhood trauma, and to assess for effect modification by social support.

RESULTS

Major depressive disorder had a statistically significant association with emotional abuse (adjusted relative risk [ARR] 2.57; 95% CI 1.31-5.04; P=0.006) and physical abuse (ARR 2.16; 95% CI 1.19-3.89; P=0.01). The estimated association between any abuse and major depressive disorder was statistically significant among those with a low level of social support (ARR 4.30; 95% CI 1.64-11.25; P=0.003) but not among those with a high level of social support (ARR 1.30; 95% CI 0.57-2.98; P=0.52). Suicidality also had a statistically significant association with emotional abuse (ARR 2.03; 95% CI 1.05-3.920; P=0.03) and physical abuse (ARR 3.17; 95% CI 1.60-6.25.; P=0.001), but no differences by social support were noted.

LIMITATIONS

Corporal punishment is used widely in schools and homes as a form of discipline in Uganda; this cultural practice could have biased reporting about physical abuse.

CONCLUSIONS

Childhood trauma is associated with poor mental health among ALHIV, but its effects may be moderated by social support. More research is needed to develop social support interventions for ALHIV with adverse childhood experiences for improved mental health outcomes.

Beyond Their HIV Status: the Occurrence of Multiple Health Risk Behavior Among Adolescents from a Rural Setting of Sub-Saharan Africa

Background

Health risk behaviors during adolescence may cluster into patterns that might be predicted by specific factors, among which HIV may have an important role.

Method

In a cross-sectional study conducted between 2017 and 2018, clustering of HRB and its associated factors was investigated in rural Kenya among 588 adolescents (36% perinatally HIV infected; 28% perinatally HIV exposed but uninfected; and 36% HIV unexposed/uninfected). Latent class analysis of 22 behaviors followed by multinomial logistic regression were conducted. Four risk behavior classes were identified.

Results

No significant differences were found in behavioral class membership across the three HIV groups (p = 0.366). The risk of membership to the higher risk behavioral classes relative to class 1 (the substance and drug abstinent low risk takers) increased with older adolescent age (p = 0.047), increased among adolescent who experienced mental distress (p < 0.001), and those who felt unsafe in their neighborhood (p < 0.002). Better working memory (p = 0.0037) was found to be protective.

Conclusion

The results highlight a need to include screening and interventions for internalizing mental health problems and deficits in executive functioning, as well as steps to involve family members and communities to address psychosocial risk factors in adolescents in Kenya.

Adaptation of the WHO group interpersonal therapy for people living with HIV/AIDS in Northwest Ethiopia: A qualitative study

BACKGROUND

Psychological treatments improve depressive symptoms in people living with HIV/AIDS (PLWHA). Adaptation of treatments should be based on explanatory models of depression and other elements within the given context.

AIM

This study aimed to examine explanatory models of depression and acceptable approaches for implementation of group IPT in Northwest Ethiopia.

METHODS

Qualitative data were collected from April to May 2019 from case managers, adherence supporters and service users using focus group discussion and analysed thematically.

RESULTS

PLWHA attributed depression to psychosocial problems, spiritual factors and biological factors. Depression had several impacts at individual and family level. Group-based interpersonal therapy (IPT) was acceptable if provided by trained peer counselors.

CONCLUSION

The current study findings informed how to conduct feasibility and acceptability trials of group IPT in the HIV population in Ethiopia.

The prevalence of mental health problems in sub-Saharan adolescents living with HIV: a systematic review

Despite the progress made in HIV treatment and prevention, HIV remains a major cause of adolescent morbidity and mortality in sub-Saharan Africa. As perinatally infected children increasingly survive into adulthood, the quality of life and mental health of this population has increased in importance. This review provides a synthesis of the prevalence of mental health problems in this population and explores associated factors. A systematic database search (Medline, PsycINFO, Scopus) with an additional hand search was conducted. Peer-reviewed studies on adolescents (aged 10-19), published between 2008 and 2019, assessing mental health symptoms or psychiatric disorders, either by standardized questionnaires or by diagnostic interviews, were included. The search identified 1461 articles, of which 301 were eligible for full-text analysis. Fourteen of these, concerning HIV-positive adolescents, met the inclusion criteria and were critically appraised. Mental health problems were highly prevalent among this group, with around 25% scoring positive for any psychiatric disorder and 30-50% showing emotional or behavioral difficulties or significant psychological distress. Associated factors found by regression analysis were older age, not being in school, impaired family functioning, HIV-related stigma and bullying, and poverty. Social support and parental competence were protective factors. Mental health problems among HIV-positive adolescents are highly prevalent and should be addressed as part of regular HIV care.

Community beliefs, HIV stigma, and depression among adolescents living with HIV in rural Uganda

The availability of and increased access to antiretroviral therapy (ART) has significantly reduced the morbidity and mortality associated with HIV. As a result, perinatally infected youth are increasingly able to reach adolescence. There is limited information about the psychosocial challenges facing adolescents living with HIV (ALWH) in rural settings of sub-Saharan Africa. We sought to understand psychosocial challenges facing ALWH in rural Uganda and their effects on mental health and HIV treatment outcomes. We conducted 5 focus group discussions and 40 one-on-one in-depth interviews in Mbarara, Uganda with adolescents (aged 13-17 years) and adult women caregivers. All interviews were audio-recorded, transcribed directly into English, and coded using thematic analysis to identify themes related to psychosocial adversities and mental health. Adversities faced by adolescents included negative community perceptions (perceived aggression, presumed early mortality), HIV stigma (enacted and internalized), vulnerability factors (loss of parents, poverty), and health challenges (depression, ART non-adherence). In the conceptual model that emerged from the findings, negative community perceptions (about perceived aggression or presumed early mortality) predisposed ALWH to experience enactments and internalization of stigma that led to depression and ART non-adherence. The data also identified several protective factors, including counselling, family and religious support, and timely serostatus disclosure. Interventions to correct community misperceptions about HIV can potentially reduce stigma and thereby improve physical and mental health outcomes of ALWH.

Prevalence of depressive symptoms and associated factors among adolescents living with HIV/AIDS in South Western Uganda

Adolescents living with HIV (ALHIV) are prone to depression, which can have detrimental effects including disease progression, poor treatment adherence and mortality. We aimed to determine the prevalence of depressive symptoms and their associated factors among ALHIV in Uganda. We conducted a cross-sectional survey among ALHIV (10-19 years) attending urban and rural clinics in Mbarara, Uganda between March and May 2017. Presence of depressive symptoms was assessed using the Centre for Epidemiological Studies' Depression scale. We interviewed 336 adolescents with a median age of 13 years, 62% of whom were female. A third (37%) had disclosed their HIV/AIDS status and 13% were sexually active. Overall, 154 (∼46%, [95% CI: 40.5-51.2]) had depressive symptoms. On bivariate analysis, the odds of having depressive symptoms were higher among adolescents who were ≥ 15 years, had disclosed HIV status, traveled >30 min for routine care and had risky sexual practices. On multiple variable analysis, only travel time to the clinic of >30 min was independently associated with depressive symptoms (AOR = 1.6 [95% CI: 1.02-2.7]). With the high prevalence of depressive symptoms among ALHIV in Uganda, screening and prompt treatment of depression should be incorporated within their routine care.

Neurocognitive and mental health outcomes and association with quality of life among adults living with HIV: a cross-sectional focus on a low-literacy population from coastal Kenya

OBJECTIVES

Our aim was to compare the neurocognitive performance and mental health outcome of adults living with HIV on antiretroviral therapy with that of community controls, all of low literacy. Furthermore, we also wanted to explore the relationship of these outcomes with quality of life among adults living with HIV.

STUDY DESIGN

This was a descriptive cross-sectional study.

SETTING

The study was conducted in Kilifi County, a region located at the Kenyan coast.

PARTICIPANTS

The participants consisted of a consecutive sample of 84 adults living with HIV and 83 randomly selected community controls all with ≤8 years of schooling. All participants were assessed for non-verbal intelligence, verbal working memory and executive functioning. The Major Depression Inventory and a quality of life measure (RAND SF-36) were also administered.

RESULTS

Using analysis of covariance, we found no statistically significant group differences between adults living with HIV and community controls in all the neurocognitive tests except for a marginal difference in the non-verbal intelligence test (F (1, 158)=3.83, p=0.05). However, depressive scores of adults living with HIV were significantly higher than those of controls (F (1, 158)=11.56, p<0.01). Also, quality of life scores of adults living with HIV were significantly lower than those of controls (F (1, 158)=4.62, p=0.03). For the HIV-infected group, results from multivariable linear regression analysis showed that increasing depressive scores were significantly associated with poorer quality of life (β=-1.17, 95% CI -1.55 to -0.80; p<0.01).

CONCLUSION

Our findings suggest that adults of low-literacy levels living with HIV and on antiretroviral medication at the Kenyan coast do not have significant cognitive deficits compared with their uninfected counterparts. However, their mental health, compared with that of HIV-uninfected adults, remains poorer and their quality of life may deteriorate when HIV and depressive symptoms co-occur.

Cognition, mood and quality-of-life outcomes among low literacy adults living with epilepsy in rural Kenya: A preliminary study

Epilepsy is frequently associated with neurocognitive impairments, mental health, and psychosocial problems but these are rarely documented in low- and middle-income countries. The aim of this study was to examine the neurocognitive outcomes, depressive symptoms, and psychosocial adjustments of people with epilepsy (PWE) in Kilifi, Kenya. We evaluated the impact of these outcomes on health-related quality of life. Self-report, interviewer-administered measures of depression (Major Depression Inventory) and quality of life (RAND SF-36) were administered to 63 PWE and 83 community controls. Neurocognitive functioning was assessed using Raven's Standard Progressive Matrices, Digit Span, and Contingency Naming Test. The results show that PWE have poorer scores for executive function, working memory, intelligence quotient (IQ), depression, and quality of life than controls. Twenty-seven (27%) of PWE had depressive symptoms, which was significantly greater than in controls (6%); P < 0.001. Quality-of-life scores were significantly lower in PWE with depressive symptoms than in those without depressive symptoms (Mean QoL scores (standard deviation (SD)): 46.43 (13.27) versus 64.18 (17.69); P = 0.01. On adjusted linear regression models, depression affected total quality-of-life scores (P = 0.07) as well as individual health indicator domains touching on pain (P = 0.04), lethargy/fatigue (P = 0.01), and emotional well-being (P = 0.02). Our results show that epilepsy is associated with a significant burden of mental health and neurocognitive impairments in the community; however, community-based studies are needed to provide precise estimates of these disorders.