Suubi+Adherence study protocol: A family economic empowerment intervention addressing HIV treatment adherence for perinatally infected adolescents

"We did more than survive": lessons learned from studies of risk and resilience of young people growing up with HIV and mental health needs

Despite advances in HIV-treatment, adolescents and young adults (AYA) with HIV (AYAHIV) face myriad challenges. They are less likely than children and older adults to be virally suppressed and are at higher risk for mental health conditions compared to their peers who do not have HIV. AYA are also developing in the context of numerous biomedical, neurocognitive, and psychosocial developmental changes. Normative challenges during this time can be exacerbated by HIV and can result in significant physical and mental health problems. Yet, many AYAHIV have shown resilience with positive assets and resources and few health or mental health problems. Historically research has had a risk-focused approach to understanding AYAHIV needs. This paper discusses the rationale for a shift from a risk-focused only approach to one that examines AYAHIV needs from both a risk and resilience perspective. This paper presents: (1) epidemiological data on AYAHIV; (2) conceptual models for understanding both risk (e.g., poverty, stress, trauma, limited resources) and resilience/protective factors (e.g., family and peer support, future orientation, problem-solving skills); (3) global data examining risk and protective factors for physical and mental health challenges; and (4) promising interventions that incorporate elements of resilience to improve overall outcomes among AYAHIV.

The longitudinal impact of an evidence-based multiple family group intervention (Amaka Amasanyufu) on family cohesion among children in Uganda: Analysis of the cluster randomized SMART Africa-Uganda scale-up study (2016-2022)

Family functioning plays a critical role in childhood disruptive behavior disorders (The Family Journal, 2003, 11(1), 33-41; Research in Nursing and Health, 2016, 39(4), 229-243). Yet, there is limited research on the impact of evidence-based family strengthening interventions on improving family cohesion as a protective factor among children experiencing behavioral challenges. To address this gap, we analyzed data (N = 636) from the SMART Africa-Uganda study (2016-2022), a cluster randomized clinical trial testing an evidence-based family-strengthening intervention called Amaka Amasanyufu (translated as "Happy Families" in the local language). Children aged 8-13 and their caregivers were recruited from 26 public primary schools that were randomized to: (1) control condition receiving generalized psychosocial literature (10 schools), (2) intervention delivered via parent peers (eight schools), and (3) intervention delivered via community healthcare workers (eight schools). Children completed the family cohesion questionnaire at baseline, 8 weeks, 16 weeks, and 6 months post-intervention completion. The intervention effectiveness was evaluated via a three-level logistic mixed effects model with pairwise comparisons across study conditions within each time point. Participants in the parent-peer intervention group had greater odds of being in the higher family cohesion group than participants in the control group at 8 weeks (OR = 3.24), 16 weeks (OR = 1.88) and 6 months (OR = 2.07). At 8 weeks, 16 weeks, and 6 months, participants in the community health worker group had 3.98, 2.08, and 1.79 times greater odds of being in the higher family cohesion group than participants in the control group, respectively. Our findings strengthen the evidence base for Amaka Amansayufu as an effective intervention that can be utilized in SSA to improve family cohesion in families with children experiencing behavioral challenges.

Feasibility and Acceptability of Group-Based Stigma Reduction Interventions for Adolescents Living with HIV and Their Caregivers: The Suubi4Stigma Randomized Clinical Trial (2020-2022)

This study examined the feasibility and acceptability of two group-based interventions: group-cognitive behavioral therapy (G-CBT) and a family-strengthening intervention delivered via multiple family group (MFG-FS), to address HIV stigma among adolescents living with HIV (ALHIV) and their caregivers. A total of 147 adolescent -caregiver dyads from 9 health clinics situated within 7 political districts in Uganda were screened for eligibility. Of these, 89 dyads met the inclusion criteria and provided consent to participate in the study. Participants were randomized, at the clinic level, to one of three study conditions: Usual care, G-CBT or MFG-FS. The interventions were delivered over a 3-month period. While both adolescents and their caregivers attended the MFG-FS sessions, G-CBT sessions were only attended by adolescents. Data were collected at baseline, 3 and 6-months post intervention initiation. The retention rate was 94% over the study period. Across groups, intervention session attendance ranged between 85 and 92%, for all sessions. Fidelity of the intervention was between 85 and 100%, and both children and caregivers rated highly their satisfaction with the intervention sessions. ALHIV in Uganda, and most of sub-Saharan Africa, are still underrepresented in stigma reduction interventions. The Suubi4Stigma study was feasible and acceptable to adolescents and their caregivers -supporting testing the efficacy of the interventions in a larger trial.

A Cluster-Randomized Controlled Trial of an Economic Strengthening Intervention to Enhance Antiretroviral Therapy Adherence among Adolescents Living with HIV

We examined the impact of an economic empowerment intervention on ART adherence among ALHIV. We used data from 455 ALHIV, randomized into intervention, n = 111, and control n = 344. ALHIV were aged 12-16 and recruited from 39 clinics in Uganda between January 2013 and December 2015. The intervention comprised a long-term child development account (CDA), micro-enterprise workshops, and educational sessions. Adherence was measured using unannounced pill counts. We used mixed-effects logistic regression analysis to examine the effect of the intervention on ART adherence. The mean age was 12.6 years. Despite observing non-significant group main effects, we found significant group-by-time interaction effects χ2(5) = 45.41, p < 0.001. Pairwise comparisons showed that compared to the control group, participants who received the intervention had significantly higher adherence at visit four, OR = 1.52 (95% CI: 1.07-2.18), p = 0.020; visit five, OR = 1.59 (95% CI: 1.06-2.38), p = 0.026; and visit six, OR = 1.94 (95% CI: 1.24-3.04), p = 0.004. Efforts to support ALHIV to live longer and healthier lives should incorporate components addressing poverty. However, declining adherence raises concerns over ALHIV's long-term well-being. The trial was registered at ClinicalTrials.gov, registration number NCT01790373, with a primary outcome of adherence to HIV treatment.

The impact of COVID-19 changes and disruptions on generalized anxiety disorder among young adults living with HIV (YLHIV) in Uganda

In the context of the COVID-19 pandemic, we investigated associations between specific COVID-19-related changes and its impact on generalized anxiety disorder (GAD) levels among vulnerable young adults living with HIV (YALHIV) in a low-resource setting in Southern Uganda. This research utilized data from 500 YALHIV aged 19 to 25 from the Suubi+Adherence-R2 COVID-19 Supplement study. Disruptions were assessed using an 8-item modified Coronavirus Impact Scale, while anxiety was measured with the GAD-7 questionnaire. Hierarchical logistic regression analysis and multivariate linear regression were employed, guided by the Social Determinants of Health framework. Key findings highlighted changes in routines, family income, stress from the pandemic, changes in family stress and discord, and reduced access to mental health services heightened levels of probable GAD for YALHIV during the pandemic. Additionally, female young adults showed greater levels than males. These results underscore the urgency to develop tailored support mechanisms for YALHIV, especially during challenging and unprecedented times.

A qualitative analysis of self-management needs of adolescents and young adults living with perinatally acquired HIV in rural, southwestern Uganda

The number of adolescents living with HIV remains high in sub-Saharan Africa with poorer HIV treatment outcomes among adolescents and young adults compared to individuals in other age groups. For adolescents and young adults living with perinatally acquired HIV (AYLPHIV), the transition from pediatric to adult HIV care is a particularly high-risk period. We conducted a qualitative study to understand self-management needs of AYLPHIV in rural, southwestern Uganda as they prepare to transition to adult HIV care in order to inform relevant interventions that can enable AYLPHIV acquire the necessary skills to manage their illness as they age into adulthood. We conducted 60 in-depth interviews with AYLPHIV (n = 30), caregivers (n = 20) and health care providers (n = 10) from the HIV clinic at Mbarara Regional Referral Hospital. We used an interview guide that focused on perceptions about transition to adult HIV care, challenges with transitioning, navigating HIV care, and self-management needs for AYLPHIV (from the perspectives of AYLPHIV, their caregivers, and health care providers). We used thematic analysis to identify themes related to AYLPHIV's self-management skills. We identified several self-management needs that we grouped under two major themes; social support and empowerment for AYLPHIV to assume responsibility for their own health and to navigate adult HIV care independently. The sub-themes under social support were information support, instrumental support, and emotional support as the sub themes while sub-themes under empowerment included self-advocacy skills, interpersonal skills, self-care skills, and disclosure skills. Taken together, these findings indicate that AYLPHIV need to be supported and empowered to maximize their chances of successfully transitioning to adult HIV care. Support comes from peers and caregivers. AYLPHIV require knowledge about their HIV status and empowerment with different skills including: self-advocacy skills, interpersonal skills, self-care skills, and HIV status disclosure skills, in order to assume responsibilities related to independent HIV care.

An mHealth Intervention to Address Depression and Improve Antiretroviral Therapy Adherence Among Youths Living With HIV in Uganda: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

People living with HIV often struggle with mental health comorbidities that lower their antiretroviral therapy (ART) adherence. There is growing evidence that depression treatment may improve ART adherence and result in improved HIV outcomes. Given that mental health services are severely underequipped in low-resource settings, including in Uganda, new solutions to increase access to mental health care and close the treatment gap are urgently needed. This protocol paper presents the Suubi-Mhealth study, which proposed to develop a mobile health (mHealth) intervention for use among Ugandan youths (14-17 years) with comorbid HIV and depression, taking into account their unique contextual, cultural, and developmental needs.

OBJECTIVE

The proposed study is guided by the following objectives: (1) to develop and iteratively refine an intervention protocol for Suubi-Mhealth based on formative work to understand the needs of youths living with HIV; (2) to explore the feasibility and acceptability of Suubi-Mhealth on a small scale to inform subsequent refinement; (3) to test the preliminary impact of Suubi-Mhealth versus a waitlist control group on youths' outcomes, including depression and treatment adherence; and (4) to examine barriers and facilitators for integrating Suubi-Mhealth into health care settings.

METHODS

Youths will be eligible to participate in the study if they are (1) 14-17 years of age, (2) HIV-positive and aware of their status, (3) receiving care and ART from one of the participating clinics, and (4) living within a family. The study will be conducted in 2 phases. In phase 1, we will conduct focus group discussions with youths and health care providers, for feedback on the proposed intervention content and methods, and explore the feasibility and acceptability of the intervention. In phase II, we will pilot-test the preliminary impact of the intervention on reducing depression and improving ART adherence. Assessments will be conducted at baseline, 1-, 2-, and 6-months post intervention completion.

RESULTS

Participant recruitment for phase 1 is completed. Youths and health care providers participated in focus group discussions to share their feedback on the proposed Suubi-Mhealth intervention content, methods, design, and format. Transcription and translation of focus group discussions have been completed. The team is currently developing Suubi-Mhealth content based on participants' feedback.

CONCLUSIONS

This study will lay important groundwork for several initiatives at the intersection of digital therapeutics, HIV treatment, and mental health, especially among sub-Saharan African youths, as they transition through adolescence and into adult HIV care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05965245; https://clinicaltrials.gov/study/NCT05965245.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54635.

Mobile Phone Technology for Preventing HIV and Related Youth Health Problems, Sexual Health, Mental Health, and Substance Use Problems in Southwest Uganda (Youth Health SMS): Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

East and Southern Africa have the highest HIV incidence and prevalence in the world, with adolescents and young adults being at the greatest risk. Despite effective combination prevention tools, including the recently available pre-exposure prophylaxis (PrEP), HIV incidence among adolescents and young adults in Uganda remains high, and PrEP use remains low. Mental health and substance use (behavioral health) play a role in sexual behavior and decision-making, contributing to an increase in the risk for acquiring HIV. Interventions that target multiple HIV risk factors, including sexual and mental health and problematic substance use, are crucial to ending the HIV epidemic. Yet few interventions addressing HIV related health disparities and comorbidities among adolescents and young adults in East and Southern Africa currently exist.

OBJECTIVE

This study aims to evaluate the acceptability and feasibility of Kirabo, an SMS text message intervention informed by the information, motivation, and behavior model and to be disseminated through secondary schools. The study will gather preliminary estimates of Kirabo's effectiveness in increasing HIV testing and linking users to mental health counselors.

METHODS

We identified Mobile 4 Reproductive Health for adaptation using the assessment, decision, administration, production, topical experts, integration, training, testing (ADAPT-ITT) framework. Mobile 4 Reproductive Health is an evidence-based automated 2-way SMS text messaging and interactive voice response platform that offers sexual and reproductive health information and links users to HIV clinics in East Africa. Through ADAPT-ITT we refined our approach and created Kirabo, an SMS text message-based intervention for linking adolescents and young adults to health services, including HIV testing and mental health counseling. We will conduct a 2-arm randomized controlled trial in Masaka, Uganda. Adolescents (N=200) will be recruited from local schools. Baseline sociodemographic characteristics, HIV test history, and behavioral health symptoms will be assessed. We will evaluate acceptability and feasibility using surveys, interviews, and mobile phone data. The preliminary efficacy of Kirabo in increasing HIV testing and linking users to mental health counselors will be evaluated immediately after the intervention and at the 3-month follow-up. We will also assess the intervention's impact on self-efficacy in testing for HIV, adopting PrEP, and contacting a mental health counselor.

RESULTS

Intervention adaptation began in 2019. A pretest was conducted in 2021. The randomized controlled trial, including usability and feasibility assessments and effectiveness measurements, commenced in August 2023.

CONCLUSIONS

Kirabo is a tool that assists in the efforts to end the HIV epidemic by targeting the health disparities and comorbidities among adolescents in Uganda. The intervention includes local HIV clinic information, PrEP information, and behavioral health screening, with referrals as needed. Increasing access to prevention strategies and mitigating factors that make adolescents and young adults susceptible to HIV acquisition can contribute to global efforts to end the HIV epidemic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05130151; https://clinicaltrials.gov/study/NCT05130151.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/49352.

Using Hierarchical Regression to Examine the Predictors of Sexual Risk-Taking Attitudes among Adolescents Living with Human Immunodeficiency Virus in Uganda

PURPOSE

We explored the factors influencing sexual risk-taking attitudes-defined as beliefs and values regarding sexual activity-among adolescents living with human immunodeficiency virus (ALHIV) in Uganda.

METHODS

The study used baseline data from a five-year cluster-randomized control trial (2012-2018) among 702 ALHIV in Uganda. Participants were aged 10-16 years, HIV-positive, taking antiretroviral therapy, and living within a family. We fitted hierarchical regression models to assess the demographic, economic, psychological, and social predictors of sexual risk-taking attitudes. Using R2, the final model explained 11.4% of the total variance.

RESULTS

Under economic factors, caregiver being formally employed (β = -0.08, 95% confidence interval [CI]: -0.10-0.06, p < .001), and the ALHIV working for pay (β = 1.78, 95% CI: 0.28-3.29, p = .022), were associated with sexual risk-taking attitudes. Among the psychological factors, more depressive symptoms (β = 0.22, 95% CI: 0.11-0.32, p < .001) were associated with more approving attitudes toward sexual risk-taking. Family and social factors including communicating with the caregiver about HIV (β = 1.32, 95% CI: 0.56-2.08, p = .001), sex (β = 1.09, 95% CI: 0.20-1.97, p = .017), and experiencing peer pressure (β = 3.37, 95% CI: 1.85-4.89, p < .001) were also associated with more approving attitudes toward sexual risk-taking. The final model explained 11.54% of the total variance.

DISCUSSION

Economic, psychological, and social factors influence sexual risk-taking attitudes among ALHIV. There is a need for more research to understand why discussing sex with caregivers improves adolescents' positive attitudes toward sexual risk-taking. These findings have significant ramifications in preventing sexual transmission of HIV among adolescents in low-income settings.

The relationship between life satisfaction, personal health, quality of life, and medication adherence among adolescents living with HIV in southwestern Uganda

Purpose

Adolescents living with HIV (ALHIV) are at high risk for adherence to antiretroviral (ART) treatment and poor health-seeking behaviors, both of which potentially compromise their quality of and satisfaction with life. This study, therefore, seeks to examine the relationship between physical health, pediatric quality of life, life satisfaction, and medication adherence among ALHIV in southwestern Uganda.

Methods

Baseline data from the Suubi+Adherence study, 2012-2018, that recruited 702 adolescents, aged 10-16 years, living with HIV in Uganda were analyzed. To account for overdispersion, negative binomial regression analyses were used to examine the impact of physical health, pediatric quality of life, and life satisfaction on self-reported medication adherence. We controlled for participants' socio-demographic factors.

Results

Results indicated that after adjusting for socio-demographic characteristics, adolescents' reported satisfaction with life was associated with a decrease in the reported number of days missed taking medication by 41.2% (IRR (incidence risk ratio)=0.588; p (p-value)=0.014). On the other hand, the low level of pediatric quality of life was associated with a 5% increase in the reported number of days missed taking medication (IRR=1.055, p=0.044). Personal health was not statistically significant in the model.

Conclusion

Our study findings indicated that quality of life and life satisfaction are significantly associated with antiretroviral (ART) medication among ALHIV. Hence, strengthening existing support systems and creating additional support for optimal ART adherence and treatment outcomes for ALHIV in low-resource communities might be beneficial. Moreover, with the increasing HIV prevalence rates among adolescents, effective and comprehensive efforts that are responsive to the special needs of ALHIV must be developed to ensure optimal adherence to ART medication as it leads to low vertical infection and superinfection rates.

Assessing the Feasibility of Economic Approaches to Prevent Substance Abuse Among Adolescents: Protocol for a Mixed Methods Study

BACKGROUND

Adolescent alcohol and drug use (ADU) is a significant public health challenge. Uganda, one of the poorest countries in Sub-Saharan Africa (SSA), has the second-highest rate of per capita alcohol consumption in SSA, and over one-third of Ugandan adolescents have used alcohol in their lifetime (over 50% of them engage in heavy episodic drinking). These estimates further increase in fishing villages, a key HIV-vulnerable population, where ADU is normative. However, few studies have assessed ADU among adolescents and youths living with HIV despite their increased risk for ADU and its impact on engagement in HIV care. Moreover, data on risk and resilience factors for ADU are scarce as only few studies evaluating ADU interventions in SSA have reported positive outcomes. The majority have been implemented in school settings, potentially excluding adolescents in fishing communities with high school dropout rates, and none have targeted risk factors including poverty and mental health, which are rampant among adolescents and youths living with HIV and their families, undermine their coping skills and resources, and have been associated with increased risk for ADU among them.

OBJECTIVE

We propose a mixed methods study with a sample of 200 adolescents and youths living with HIV (aged 18-24 years) seen at 6 HIV clinics in southwestern Uganda's fishing communities to (1) examine the prevalence and consequences of ADU and identify the multilevel risk and resilience factors associated with ADU among them and (2) explore the feasibility and short-term effects of an economic empowerment intervention on ADU among them.

METHODS

This study comprises four components: (1) focus group discussions (FGDs) with adolescents and youths living with HIV (n=20) and in-depth qualitative interviews with health providers (n=10) from 2 randomly selected clinics; (2) a cross-sectional survey with 200 adolescents and youths living with HIV; (3) a randomized controlled trial with a subgroup of adolescents and youths living with HIV (n=100); and (4) 2 postintervention FGD with adolescents and youths living with HIV (n=10 per group).

RESULTS

Participant recruitment for the first qualitative phase has completed. As of May 4, 2023, ten health providers from 6 clinics have been recruited, provided written consent to participate, and participated in in-depth qualitative interviews. Two FGDs was conducted with 20 adolescents and youths living with HIV from 2 clinics. Data transcription, translation, and analysis of qualitative data has commenced. The cross-sectional survey will commence shortly after and dissemination of the main study findings is targeted for 2024.

CONCLUSIONS

Our findings will advance our understanding of ADU among adolescents and youths living with HIV and inform the design of future interventions to address ADU among them.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05597865; https://clinicaltrials.gov/ct2/show/NCT05597865.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46486.

The effect of family support on self-reported adherence to ART among adolescents perinatally infected with HIV in Uganda: A mediation analysis

INTRODUCTION

This study examined the mechanisms through which family support affects self-reported adherence to antiretroviral therapy among adolescents perinatally infected with HIV in Uganda.

METHODS

Longitudinal data from 702 adolescent boys and girls (10-16 years) were analyzed. Structural equation models were conducted to assess the direct, indirect, and total effects of family support on adherence.

RESULTS

Results showed a significant indirect effect of family support on adherence (β = .112, 95% confidence interval [CI]: 0.052-0.173, p < .001). Specific indirect effects of family support through saving attitudes (β = .058, 95% CI: 0.008-0.108, p = .024), and communication with the guardian (β = .056, 95% CI: 0.012-0.100), p = .013), as well as the total effect of family support on adherence (β = .146 (95% CI: 0.032-0.259, p = .012), were statistically significant. Mediation contributed 76.7% of the total effects.

CONCLUSION

Findings support strategies to help promote family support and strengthen open communication between adolescents living with HIV and their caregivers.

A Structural Equation Model of the Impact of a Family-Based Economic Intervention on Antiretroviral Therapy Adherence Among Adolescents Living With HIV in Uganda

PURPOSE

Antiretroviral therapy (ART) adherence among adolescents living with HIV (ALWHIV) is low, with poverty remaining a significant contributor. We examined the mediation pathways between an economic empowerment intervention and ART adherence among ALWHIV.

METHODS

This cluster-randomized controlled trial (2012-2018) recruited 702 ALWHIV aged 10-16 in Uganda between January 2014 and December 2015. We randomized 39 clinics into the control (n = 344) or intervention group (n = 358). The intervention comprised a child development account, four microenterprise workshops, and 12 mentorship sessions. We used six self-reported items to measure adherence at 24 months, 36 months, and 48 months. We used structural equation modeling to assess the mediation effects through mental health and adherence self-efficacy, on adherence. We ran models corresponding to the 24, 36, and 48 months of follow-up.

RESULTS

The mean age of the participants was 12 years, and 56% were female. At 36 (model 2) and 48 months (model 3), the intervention had a significant indirect effect on ART adherence [B = 0.069, β = 0.039 (95% confidence interval [CI]: 0.005-0.074)], and [B = 0.068, β = 0.040 (95% CI: 0.010-0.116)], respectively. In both models, there was a specific mediation effect through mental health [B = 0.070, β = 0.040 (95% CI: 0.007-0.063)], and [B = 0.039, β = 0.040 (95% CI: 0.020-0.117)]. Overall, 49.1%, 90.7%, and 36.8% of the total effects were mediated in models, 1, 2, and 3, respectively.

DISCUSSION

EE interventions improve adherence, by improving mental health functioning. These findings warrant the need to incorporate components that address mental health challenges in programs targeting poverty to improve ART adherence in low-income settings.

Suubi + Adherence4Youth: a study protocol to optimize the Suubi Intervention for Adherence to HIV treatment for youth living with HIV in Uganda

BACKGROUND

Suubi is an evidenced based multi-component intervention that targets psychosocial and economic hardships to improve ART adherence, viral suppression, mental health, family financial stability, and family cohesion for adolescents living with HIV (ALHIV) in Uganda. Suubi was originally tested as a combined package of four components: 1) Financial Literacy Training; 2) incentivized matched Youth Savings Accounts with income-generating activities; 3) a manualized and visual-based intervention for ART adherence and stigma reduction; and 4) engagement with HIV treatment-experienced role models. However, it is unknown if each component in Suubi had a positive effect, how the components interacted, or if fewer components could have produced equivalent effects. Hence, the overall goal of this new study is to identify the most impactful and sustainable economic and psychosocial components across 48 health clinics in Uganda.

METHODS

A total of 576 ALHIV (aged 11-17 years at enrollment) will be recruited from 48 clinics and each clinic will be randomized to one of 16 study conditions. Each condition represents every possible combination of the 4 components noted above. Assessments will be conducted at baseline, 12, 24, 36 and 48- months post-intervention initiation. Using the multi-phase optimization strategy (MOST), we will identify the optimal combination of components and associated costs for viral suppression, as well as test key mediators and moderators of the component-viral suppression relationship.

DISCUSSION

The study is a shift in the paradigm of research to use new thinking to build/un-pack highly efficacious interventions that lead to new scientific knowledge in terms of understanding what drives an intervention's success and how to iterate on them in ways that are more efficient, affordable and scalable. The study advances intervention science for HIV care outcomes globally.

TRIAL REGISTRATION

This project was registered at clinicaltrials.gov (NCT05600621) on October, 31, 2022. https://clinicaltrials.gov/ct2/show/NCT05600621.

Addressing the Know-Do Gap in Adolescent HIV: Framing and Measuring Implementation Determinants, Outcomes, and Strategies in the AHISA Network

Implementation science (IS) uses systematic methods to close gaps between research and practice by identifying and addressing barriers to implementation of evidence-based interventions (EBIs). To reach UNAIDS HIV targets, IS can support programs to reach vulnerable populations and achieve sustainability. We studied the application of IS methods in 36 study protocols that were part of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA). Protocols focused on youth, caregivers, or healthcare workers in high HIV-burden African countries and evaluated medication, clinical and behavioral/social EBIs. All studies measured clinical outcomes and implementation science outcomes; most focused on early implementation outcomes of acceptability (81%), reach (47%), and feasibility (44%). Only 53% used an implementation science framework/theory. Most studies (72%) evaluated implementation strategies. Some developed and tested strategies, while others adapted an EBI/strategy. Harmonizing IS approaches allows cross study learning and optimization of delivery of EBIs and could support attainment of HIV goals.

The Impact of an Economic Strengthening Intervention on Academic Achievement Among Adolescents Living with HIV: Findings from the Suubi + Adherence Cluster-Randomized Trial in Uganda (2012-2018)

We examined the impact of a family-based economic strengthening intervention on school dropout and repeating a class among ALWHIV in Uganda. In this cluster-randomized trial (2012-2018) conducted in 39 clinics, we recruited adolescents aged 10-16 years living with HIV. We included data from 613 adolescents. We plotted a Kaplan Meier survival curve and fitted Cox proportional hazards models to test the effect of the economic strengthening intervention on school dropout. The incidence of school dropout was 13.0% and 9.6% in the control and intervention groups, respectively. Also, economic empowerment reduced the risk of school dropout, aHR = 0.68 (95% CI 0.52-0.88), p-value 0.004. In other words, participants in the intervention group had 32% reduced hazards of dropping out of school. Also, increasing age aHR = 1.54 (95% CI 1.42-1.66), p-value < 0.001 and double orphanhood aHR = 0.67 (95% CI 0.47-0.96) p-value 0.030 increased the risks for dropping out of school. The intervention was not efficacious in reducing the rates of repeating a class. The intervention offered the ALWHIV an opportunity to live a productive adult life. More research is required on these kinds of interventions intended to keep ALWHIV and those impacted by HIV in school.

Self-Reported Adherence to Antiretroviral Therapy (ART) Among Women Engaged in Commercial Sex Work in Southern Uganda

We examined the correlates of self-reported adherence to antiretroviral therapy (ART) among women engaged in commercial sex work (WESW) in Uganda. We used baseline data from a longitudinal study, which recruited 542 WESW in Southern Uganda. We used nested regression models to determine the individual and family, and economic level correlates of self-reported adherence. Study findings show that older age (OR = 1.07, 95% CI = 1.013, 1.139), secondary education (OR = 2.01, 95% CI = 1.306, 3.084), large household size (OR = 1.08, 95% CI = 1.020, 1.136), high family cohesion (OR = 1.06, 95% CI = 1.052, 1.065), and high financial self-efficacy (OR = 1.07, 95% CI = 1.006, 1.130) were associated with good self-reported adherence to ART. Married women (OR=-0.39, 95% CI = 0.197, 0.774), depression (OR = 0.85, 95% CI = 0.744, 0.969), alcohol use (OR = 0.72, 95% CI = 0.548, 0.954), ever been arrested (OR = 0.58, 95% CI = 0.341, 0.997), and high household assets ownership (OR = 0.48, 95% CI = 0.313, 0.724) were associated with poor self-reported adherence to ART. Findings suggest a need to adopt a multi-level approach to address gaps in ART adherence among WESW.

Economic costs and cost-effectiveness of conditional cash transfers for the uptake of services for the prevention of vertical HIV transmissions in a resource-limited setting

BACKGROUND

Prevention of mother-to-child transmission (PMTCT) is critical for halting the HIV epidemic. However, innovative approaches to improve PMTCT uptake may be resource-intensive. We examined the economic costs and cost-effectiveness of conditional cash transfers (CCTs) for the uptake of PMTCT services in the Democratic Republic of Congo.

METHODS

We leveraged data from a randomized controlled trial of CCTs (n = 216) versus standard PMTCT care alone (standard of care (SOC), n = 217). Economic cost data came from multiple sources, with costs analyzed from the societal perspective and reported in 2016 international dollars (I$). Effectiveness outcomes included PMTCT uptake (i.e., accepting all PMTCT visits and services) and retention (i.e., in HIV care at six weeks post-partum). Generalized estimating equations estimated effectiveness (relative risk) and incremental costs, with incremental effectiveness reported as the number of women needing CCTs for an additional PMTCT uptake or retention. We evaluated the cost-effectiveness of the CCTs at various levels of willingness-to-pay and assessed uncertainty using deterministic sensitivity analysis and cost-effectiveness acceptability curves.

RESULTS

Mean costs per participant were I$516 (CCTs) and I$431 (SOC), representing an incremental cost of I$85 (95% CI: 59, 111). PMTCT uptake was more likely for CCTs vs SOC (68% vs 53%, p < 0.05), with seven women needing CCTs for each additional PMTCT service uptake; twelve women needed CCTs for an additional PMTCT retention. The incremental cost-effectiveness of CCTs vs SOC was I$595 (95% CI: I$550, I$638) for PMTCT uptake and I$1028 (95% CI: I$931, I$1125) for PMTCT retention. CCTs would be an efficient use of resources if society's willingness-to-pay for an additional woman who takes up PMTCT services is at least I$640. In the worst-case scenario, the findings remained relatively robust.

CONCLUSIONS

Given the relatively low cost of the CCTs, policies supporting CCTs may decrease onward HIV transmission and expedite progress toward ending the epidemic.

Impact of Family-Based Economic Empowerment Intervention, Suubi+Adherence (2012-2018) on Multidimensional Poverty for Adolescents Living with HIV (ALWHIV) in Uganda

Children growing up in poverty are disproportionately affected by diseases, including HIV. In this study, we use data from Suubi+Adherence, a longitudinal randomized control trial (2012-2018) with 702 adolescents living with HIV (ALWHIV), to examine the effectiveness of a family-based multifaceted economic empowerment (EE) intervention in addressing economic instability and multidimensional poverty among ALWHIV in Southern Uganda. We constructed a Multidimensional Poverty Index of individual and household indicators, including health, assets, housing and family dynamics. We computed the proportion of multidimensionally poor children (H), estimated poverty intensity (A) and adjusted headcount ratio (M₀). Using repeated measures at five-time points (baseline, years 1, 2, 3 and 4-post baseline) across two study arms: treatment (receiving the EE intervention) vs. control arm (not receiving EE), we find that both the incidence and proportion of multidimensional poverty decreased in the treatment arm vs. the control arm. Given that there is a direct link between economic instability and poor health outcomes, these findings are informative. They point to the potential for family EE interventions to decrease multidimensional poverty among vulnerable children, including ALWHIV, impacting their overall wellbeing and ability to meet their treatment needs and improve HIV care continuum outcomes.

A Multilevel Integrated Intervention to Reduce the Impact of HIV Stigma on HIV Treatment Outcomes Among Adolescents Living With HIV in Uganda: Protocol for a Randomized Controlled Trial

BACKGROUND

HIV stigma remains a formidable barrier to HIV treatment adherence among school-attending adolescents living with HIV, owing to high levels of HIV stigma within schools, rigid school structures and routines, lack of adherence support, and food insecurity. Thus, this protocol paper presents an evidence-informed multilevel intervention that will simultaneously address family- and school-related barriers to HIV treatment adherence and care engagement among adolescents living with HIV attending boarding schools in Uganda.

OBJECTIVE

The proposed intervention-Multilevel Suubi (MSuubi)-has the following objectives: examine the impact of M-Suubi on HIV viral suppression (primary outcome) and adherence to HIV treatment, including keeping appointments, pharmacy refills, pill counts, and retention in care; examine the effect of M-Suubi on HIV stigma (internalized, anticipated, and enacted), with secondary analyses to explore hypothesized mechanisms of change (eg, depression) and intervention mediation; assess the cost and cost-effectiveness of each intervention condition; and qualitatively examine participants' experiences with HIV stigma, HIV treatment adherence, and intervention and educators' attitudes toward adolescents living with HIV and experiences with group-based HIV stigma reduction for educators, and program or policy implementation after training.

METHODS

MSuubi is a 5-year multilevel mixed methods randomized controlled trial targeting adolescents living with HIV aged 10 to 17 years enrolled in a primary or secondary school with a boarding section. This longitudinal study will use a 3-arm cluster randomized design across 42 HIV clinics in southwestern Uganda. Participants will be randomized at the clinic level to 1 of the 3 study conditions (n=14 schools; n=280 students per study arm). These include the bolstered usual care (consisting of the literature on antiretroviral therapy adherence promotion and stigma reduction), multiple family groups for HIV stigma reduction plus family economic empowerment (MFG-HIVSR plus FEE), and Group-based HIV stigma reduction for educators (GED-HIVSR). Adolescents randomized to the GED-HIVSR treatment arm will also receive the MFG-HIVSR plus FEE treatment. MSuubi will be provided for 20 months, with assessments at baseline and 12, 24, and 36 months.

RESULTS

This study was funded in September 2021. Participant screening and recruitment began in April 2022, with 158 dyads enrolled as of May 2022. Dissemination of the main study findings is anticipated in 2025.

CONCLUSIONS

MSuubi will assess the effects of a combined intervention (family-based economic empowerment, financial literacy education, and school-based HIV stigma) on HIV stigma among adolescents living with HIV in Uganda. The results will expand our understanding of effective intervention strategies for reducing stigma among HIV-infected and noninfected populations in Uganda and improving HIV treatment outcomes among adolescents living with HIV in sub-Saharan Africa.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05307250; https://clinicaltrials.gov/ct2/show/NCT05307250.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/40101.

The Long-term (5-year) Impact of a Family Economic Empowerment Intervention on Adolescents Living with HIV in Uganda: Analysis of Longitudinal Data from a Cluster Randomized Controlled Trial from the Suubi+Adherence Study (2012-2018)

150/150 words.We examined the 5-year impact of an economic empowerment (EE) intervention on: adherence, viral suppression, sexual risk-taking intentions (primary); and physical health, educational and economic (secondary) outcomes among adolescents living with HIV in Uganda. The Suubi + Adherence study (2012-2018) randomized clinics to: (1) Control group, n = 19 clinics, n = 344 participants; (2) intervention group which received matched savings accounts, mentorship, financial management and, business development training, n = 20 clinics, n = 358 participants. Participants completed post-baseline assessments at 12-, 24-, 36-, and 48-months. No significant differences in viral load, sexual risk-intentions and physical health perception were observed. The intervention group had better adherence (at 24-months) (Contrast=-0.28; 95% CI: -0.55, -0.004), higher school enrolment (OR = 2.18; 95% CI:1.30, 3.66); reported savings OR = 2.03 (1.29, 3.18) and higher savings (Contrast = 0.40; 95% CI:0.10, 0.70) than controls at 48-months. The EE intervention was efficacious in improving adherence, school enrolment, and economic outcomes creating opportunities for improved overall health among adolescents living with HIV.

Monitoring adherence to antiretroviral therapy among adolescents in Southern Uganda: comparing Wisepill to Self-report in predicting viral suppression in a cluster-randomized trial

INTRODUCTION

Optimal antiretroviral therapy (ART) adherence is crucial for improved patient outcomes; however, ART adherence among adolescents living with HIV (ALHIV) is low. Also, the performance of various adherence measures among ALHIV is under contention. We monitored ART adherence and compared Self-report (SR) and Wisepill electronic monitoring (EM) performance in measuring ART adherence and predicting HIV viral suppression among ALHIV.

METHODS

Between January 2014 and December 2015, we recruited 702 ALHIV aged 10-16 years into our cluster-randomized controlled trial (2012-2018) in 39 clinics in Uganda. The intervention included a long-term savings child development account, four micro-enterprise workshops and 12 mentorship sessions. Using the entire sample, we performed multilevel logistic regression to predict monthly ART adherence trends for the first year of follow-up. Since it is possible that the intervention had different effects on SR and EM adherence, we used participants in the control arm only to compare adherence using SR and EM and to calculate their sensitivity and specificity in predicting viral suppression.

RESULTS

There was a significant decline in adherence for each month throughout the entire follow-up period regardless of the group assigned. Good ART adherence was measured at 79.2% (75.2-82.6%) and 97.0% (95.4-98.1%) using EM and SR, respectively. Overall, 64.3% (60.6-67.9%) had suppressed viral loads. The specificities for EM and SR in predicting viral non-suppression were 80.4% (73.6-85.7%) and 96.7% (93.3-98.4%), while the sensitivities were 22.9% (15.0-33.3%) and 1.8% (0.4-6.9%), respectively. The area under the curve was low for both EM and SR, at 53.6% (45.7-61.5%) and 56.2% (53.2-59.3%), respectively. There was high agreement (78%) between SR and EM in monitoring adherence.

CONCLUSIONS

Our findings highlighted the need for strategies for sustained optimal adherence. SR and EM measure adherence with a considerable agreement; however, neither is an accurate predictor of virological outcome. There is still a need for an acceptable, feasible and affordable method that predicts viral suppression among ALHIV.

Suubi4Stigma study protocol: a pilot cluster randomized controlled trial to address HIV-associated stigma among adolescents living with HIV in Uganda

BACKGROUND

Sub-Saharan Africa (SSA) is heavily burdened by HIV, with 85% of the global new infections among adolescents happening in the region. With advances in medication and national policies promoting antiretroviral therapy (ART), children < 15 years living with HIV (CLWH) continue to grow with a chronic, highly stigmatized disease. Unfortunately, the stigma they experience results in much lower quality of life, including poor mental health and treatment outcomes. Family members also experience stigma and shame by virtue of their association with an HIV-infected family member. Yet, stigma-reduction interventions targeting CLWH and their families are very limited. The goal of this study is to address HIV-associated stigma among CLWH and their caregivers in Uganda.

METHODS

This three-arm cluster randomized control trial, known as Suubi4Stigma, will evaluate the feasibility, acceptability, and preliminary impact of two evidence-based interventions: (1) group cognitive behavioral therapy (G-CBT) focused on cognitive restructuring and strengthening coping skills at the individual level and (2) a multiple family group (MFG) intervention that strengthens family relationships to address stigma among CLWH (N = 90, 10-14 years) and their families (dyads) in Uganda. Nine clinics will be randomized to one of three study arms (n = 3 clinics, 30 child-caregiver dyads each): (1) usual care; (2) G-CBT + usual care; and (3) MFG + usual care. Both treatment and control conditions  will be delivered over a 3-month period. Data will be collected at baseline (pre-intervention) and at 3 months and 6 months post-intervention initiation.

CONCLUSION

The primary aim of the proposed project is to address the urgent need for theoretically and empirically informed interventions that seek to reduce HIV-associated stigma and its negative impact on adolescent health and psychosocial well-being. As several countries in SSA grapple with care and support for CLWH, this study will lay the foundation for a larger intervention study investigating how HIV-associated stigma can be reduced to foster healthy child development-especially for CLWH as they transition through adolescence.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04528732 ; Registered August 27, 2020.

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.

Family Economic Empowerment, Family Social Support, and Sexual Risk-Taking Behaviors Among Adolescents Living With HIV in Uganda: The Suubi+Adherence Study

PURPOSE

This study examined the effect of a family economic empowerment (EE) intervention and family support on sexual risk-taking behaviors among adolescents living with HIV in rural Uganda.

METHODS

We used data from the Suubi + Adherence study, a longitudinal cluster randomized clinical trial of 702 adolescents living with HIV aged 10-16 years. Participants were randomly assigned to either the control arm (n = 358) receiving bolstered standard of care or a treatment arm (n = 344) receiving bolstered standard of care plus the family EE intervention. We used mixed-effects models to examine the effect of the EE intervention and family support on sexual risk-taking behaviors at the baseline, 12 months, and 24 months after intervention initiation.

RESULTS

Adolescents in both the intervention and control groups did not differ significantly in their sexual risk-taking attitudes at the baseline and over the 24-month follow-up period. Higher levels of caregiver social support were significantly associated with a decrease in attitudes toward sexual risk-taking (ß = -.40, 95%CI = -.51, -.29). More frequent parent-child communication was significantly associated with increased negative sexual risk-taking attitudes (ß = .21, 95%CI = .16, .26).

CONCLUSIONS

Although we find no direct relationship between family EE and attitudes related to sexual risk-taking behaviors, we find that a supportive family environment can promote positive attitudes related to sexual risk-taking behaviors. The effectiveness of sexual risk reduction interventions would be enhanced by engaging families and strengthening supportive relationships between adolescents and their caregivers.

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.

Predicting the individualized risk of poor adherence to ART medication among adolescents living with HIV in Uganda: the Suubi+Adherence study

INTRODUCTION

Achieving optimal adherence to antiretroviral therapy (ART) among adolescents living with HIV (ALWHIV) is challenging, especially in low-resource settings. To help accurately determine who is at risk of poor adherence, we developed and internally validated models comprising multi-level factors that can help to predict the individualized risk of poor adherence among ALWHIV in a resource-limited setting such as Uganda.

METHODS

We used data from a sample of 637 ALWHIV in Uganda who participated in a longitudinal study, "Suubi+Adherence" (2012 to 2018). The model was developed using the Least Absolute Shrinkage and Selection Operator (LASSO) penalized regression to select the best subset of multi-level predictors (individual, household, community or economic-related factors) of poor adherence in one year's time using 10-fold cross-validation. Seventeen potential predictors included in the model were assessed at 36 months of follow-up, whereas adherence was assessed at 48 months of follow-up. Model performance was evaluated using discrimination and calibration measures.

RESULTS

For the model predicting poor adherence, five of the 17 predictors (adherence history, adherence self-efficacy, family cohesion, child poverty and group assignment) were retained. Its ability to discriminate between individuals with and without poor adherence was acceptable; area under the curve (AUC) = 69.9; 95% CI: 62.7, 72.8. There was no evidence of possible areas of miscalibration (test statistic = 1.20; p = 0.273). The overall performance of the model was good.

CONCLUSIONS

Our findings support prediction modelling as a useful tool that can be leveraged to improve outcomes across the HIV care continuum. Utilizing information from multiple sources, the risk prediction score tool applied here can be refined further with the ultimate goal of being used in a screening tool by practitioners working with ALWHIV. Specifically, the tool could help identify and provide early interventions to adolescents at the highest risk of poor adherence and/or viral non-suppression. However, further fine-tuning and external validation may be required before wide-scale implementation.

The efficacy and cost-effectiveness of a family-based economic empowerment intervention (Suubi + Adherence) on suppression of HIV viral loads among adolescents living with HIV: results from a Cluster Randomized Controlled Trial in southern Uganda

INTRODUCTION

Evidence from low-resource settings indicates that economic insecurity is a major barrier to HIV treatment adherence. Economic empowerment (EE) interventions have the potential to improve adherence outcomes among adolescents living with HIV (ALWHIV) by mitigating the effects of poverty. This study aims to assess the efficacy and cost-effectiveness of a savings-led family-based EE intervention, Suubi + Adherence, aimed at improving antiretroviral therapy (ART) adherence outcomes ALWHIV in Uganda.

METHODS

Adolescents (mean age 12 years at enrolment; 56% female) receiving ART for HIV at 39 health centres were randomized to Suubi + Adherence intervention (n = 358) or bolstered standard of care (BSOC; n = 344). A difference-in-differences analysis was employed to assess the change in the proportion of virally suppressed adolescents (HIV RNA viral load <40 copies/mL) over 24 months. The cost-effectiveness analysis examined how much the intervention cost to virally suppress one additional adolescent relative to BSOC from the healthcare provider perspective.

RESULTS

At 24 months, the intervention was associated with an 8.85-percentage point [95% confidence interval (CI) 0.80 to 16.90 percentage points] increase in the proportion of virally suppressed adolescents between the study arms (p = 0.032). Per-participant costs were US$177 and US$263 for the BSOC and intervention groups respectively. The incremental cost of virally suppressing one additional adolescent was estimated at US$970 [95% CI, US$508 to 10,725] over two years.

CONCLUSIONS

Our results support the integration of family-based EE interventions into adherence-support strategies as part of routine HIV care in low-resource settings to address the underlying economic drivers of poor ART adherence among ALWHIV. Moreover, per-participant costs to achieve viral suppression do not seem prohibitive compared to other community-based adherence interventions targeted at ALWHIV in low-resource settings. Further research on combination interventions at the nexus of economic security and HIV treatment and care is needed to inform the development of feasible and scalable HIV policies and programmes.

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.

Engaging community and governmental partners in improving health and mental health outcomes for children and adolescents impacted by HIV/AIDS in Uganda

The African region remains the world’s most affected region in the HIV epidemic. A related consequence of HIV/AIDS in sub-Saharan Africa (SSA), including in Uganda, is the high prevalence of children and adolescents who have lost one or both parents to this virus or who have been perinatally infected. Guided by the Practical, Robust Implementation and Sustainability (PRISM) framework, this paper describes the strategies by which we have engaged community and government partners in research using three NIH-funded randomized clinical trials testing an evidence-based combination intervention aimed at improving health and mental health outcomes among children and adolescents impacted by HIV/AIDS in Uganda. We specifically lay out four strategies that have been used to facilitate stakeholder engagement, namely consultative meetings, stakeholder accountability meetings, training of key players (task-shifting), and policymaker engagement. We emphasize that community collaborations and partnerships are especially critical when implementing combination interventions that require a high level of communication and coordination among multiple implementation partners. We underline that building and sustaining long-term relationships and communication with the stakeholders can allow the researchers to successfully design rigorous studies that are responsive to local needs and can make a difference especially in low-resource settings. Finally, we highlight that the process of engagement and collaboration can be guided by conceptual frameworks.

Suubi+Adherence-Round 2: A study protocol to examine the longitudinal HIV treatment adherence among youth living with HIV transitioning into young adulthood in Southern Uganda

BACKGROUND

Youth living with HIV (YLHIV) in Sub-Saharan African (SSA) are less likely to adhere to antiretroviral therapy (ART) and other health-related regimens. As a consequence, YLHIV are not only at risk for health problems and mental health comorbidities, but are also at risk for cognitive deficits, including in areas of memory and executive functioning. The Suubi+Adherence study followed 702 adolescents (10-16 years of age) receiving bolstered standard of care and a family economic empowerment intervention comprising an incentivized youth financial savings account (YSA) augmented with financial literacy training (FLT) and peer mentorship. The study findings pointed to superior short-term viral suppression and positive adolescent health and mental health functioning among participants receiving the intervention. The original group of adolescents who received Suubi+Adherence are now transitioning into young adulthood. This paper presents a protocol for the follow-up phase titled Suubi+Adherence Round 2.

METHODS

The original cohort in Suubi+Adherence will be tracked for an additional five years (2020-2025). Specifically, the long term follow-up will allow to: 1) ascertain the extent to which the short term outcomes identified in the first 6 years of the intervention are maintained as the same group transitions through young adulthood; and 2) address new scientific questions regarding ART adherence; HIV care engagement; protective health behaviors; and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. Additionally, the team examines the potential mechanisms through which the observed long-term outcomes happen. Moreover, the Suubi+Adherence-Round 2 adds a qualitative component and extends the cost effectiveness component.

DISCUSSION

Guided by asset and human development theories, Suubi+Adherence-R2 will build on the recently concluded Suubi+Adherence study to conduct one of the largest and longest running studies of YLHIV in SSA as they transition into young adulthood. The study will address new scientific questions regarding long-term ART adherence, HIV care engagement, protective health behaviors, and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. The findings may inform efforts to improve HIV care among Uganda's YLHIV, with potential replicability in other low-resource countries.

TRIAL REGISTRATION

ClinicalTrials.gov , ID: NCT01790373.

Gender, HIV knowledge and prevention attitudes among adolescents living with HIV participating in an economic empowerment intervention in Uganda

HIV disproportionately affect adolescent girls and young women in sub-Saharan Africa. In Uganda, the HIV prevalence is four times higher in adolescent girls compared to boys. This study examined gender, HIV general and clinical knowledge, and prevention attitudes among adolescents living with HIV in Uganda. Data from a cluster randomized clinical trial were analyzed. A total of 702 adolescents (average age of 12.4) were randomized to either a control arm receiving bolstered standard of care or the treatment arm receiving bolstered standard of care plus a family economic empowerment intervention to support medication adherence. Ordinary Least Squares models that adjust for clustering of adolescents within health clinics were conducted. No gender differences were observed in HIV knowledge and prevention attitudes at baseline. However, at 12-months follow-up, boys were more likely than girls to report correct HIV general knowledge (d = 0.21), clinical knowledge (d = 0.48), and favorable prevention attitudes (d = 0.27). The intervention was not associated with any of the outcomes. Given the high HIV prevalence among adolescents, specifically girls, there is need to develop and/or tailor existing programs and interventions that equip adolescent girls with comprehensive knowledge and prevention attitudes, that are culturally appropriate, to reduce HIV transmission and reinfection within this population.

The impact of discomfort with HIV status and hopelessness on depressive symptoms among adolescents living with HIV in Uganda

Introduction: Discomfort with and reluctance to disclose HIV status can lead to depression, social isolation, and poor medication adherence; we examined relationships among these variables within a sample of adolescents living with HIV in Uganda. Methods: We used baseline data from the Suubi + Adherence study, which recruited a total of 702 adolescents (ages 10-16 years) living with HIV in southwestern Uganda. Structural equation models were conducted separately among in-school adolescents and out-of-school adolescents to assess associations between discomfort level with HIV status and depressive symptoms and if this association was mediated by hopelessness. Results: Out-of-school adolescents had significantly higher depression scores compared with those in-school youth (M = 6.24 vs. M = 5.03, p < 0.001). Although high discomfort level with HIV status was significantly associated with higher depression scores among both in-school adolescents and out-of-school adolescents, this association among out-of-school adolescents (B = 0.49, 95%CI: 0.19, 0.79), was more substantial than for in-school adolescents (B = 0.10, 95%CI: 0.03, 0.17). Discussion: One's discomfort with their HIV status and the extent to which they are hopeful about the future can contribute to the development of depressive symptoms and these factors need to be considered in the development of assessments and interventions for the treatment of depression among adolescents living with HIV.

The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda

Background

Adolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence.

Methods

Data from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy.

Results

The average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART.

Conclusion

Findings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV.

Trial registration

This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

The long-term effects of a family based economic empowerment intervention (Suubi+Adherence) on suppression of HIV viral loads among adolescents living with HIV in southern Uganda: Findings from 5-year cluster randomized trial

BACKGROUND

The rapid scale-up of HIV therapy across Africa has failed to adequately engage adolescents living with HIV (ALWHIV). Retention and viral suppression for this group (ALWHIV) is 50% lower than for adults. Indeed, on the African continent, HIV remains the single leading cause of mortality among adolescents. Strategies tailored to the unqiue developmental and social vulnerabilities of this group are urgently needed to enhance successful treatment.

METHODS

We carried out a five-year longitudinal cluster randomized trial (ClinicalTrials.gov ID: NCT01790373) with adolescents living with HIV (ALWHIV) ages 10 to 16 years clustered at health care clinics to test the effect of a family economic empowerment (EE) intervention on viral suppression in five districuts in Uganda. In total, 39 accredited health care clinics from study districts with existing procedures tailored to adolescent adherence were eligible to participate in the trial. We used data from 288 youth with detectable HIV viral loads (VL) at baseline (158 -intervention group from 20 clinics, 130 -non-intervention group from 19 clinics). The primary end point was undetectable plasma HIV RNA levels, defined as < 40 copies/ml. We used Kaplan-Meier (KM) analysis and Cox proportional hazard models to estimate intervention effects.

FINDINGS

The Kaplan-Meier (KM) analysis indicated that an incidence of undetectable VL (0.254) was significantly higher in the intervention condition compared to 0.173 (in non-intervention arm) translated into incidence rate ratio of 1.468 (CI: 1.064-2.038), p = 0.008. Cox regression results showed that along with the family-based EE intervention (adj. HR = 1.446, CI: 1.073-1.949, p = 0.015), higher number of medications per day had significant positive effects on the viral suppression (adj.HR = 1.852, CI: 1.275-2.690, p = 0.001).

INTERPRETATION

A family economic empowerment intervention improved treatment success for ALWHIV in Uganda. Analyses of cost effectiveness and scalability are needed to advance incorporation of this intervention into routine practice in low and middle-income countries.

Strengthening health care worker engagement with early adolescence in low- and middle-income countries: an overdue area for action

The very young adolescent population (ages 10-14) is currently under-served by health care systems, particularly in low- and middle-income countries. Although there is a substantial and growing effort to reach adolescents with the health services and commodities they need, such efforts often overlook the period of early adolescence given this population's lower vulnerability to risk-taking behaviors. However, early adolescence is a period of significant change, with the onset of puberty introducing physiological, emotional, and social changes in girls' and boys' lives. This period also represents a time of intensifying gendered norms, and the transition of youth from childhood focused health care (e.g. deworming programs, nutrition interventions) to additional mid- and older adolescent related care [e.g. human papilloma virus (HPV) vaccine, and contraceptive provision). Strengthening young adolescents' engagement with health care workers around preventative and promotive health behaviors could have profound impacts on their health and wellbeing, which in turn could have cascading effects across the course of their lives. Critically, young adolescents would gain trust in health care systems, and be more likely to return when significant health issues arise later in adolescence or adulthood. Such an effort requires sensitizing health care workers and building their capacity to respond to young adolescents' unique needs, by defining a package of actions that they are mandated to provide, training them, providing them with desk reference tools, and putting in place systems to provide supportive supervision and collaborative learning on the one hand, and encouraging caregivers to connect their pubescent-aged boys and girls with the health care system, on the other hand. This paper presents an argument for increased focus in particular on building attitudes and capacities of health care workers on engaging with early adolescents, applying Principle 3 of the Society of Adolescent Medicine's position paper entitled "Health Care Reform and Adolescents."

Factors Associated With HIV Disclosure and HIV-Related Stigma Among Adolescents Living With HIV in Southwestern Uganda

HIV-related stigma has been documented as one of the greatest obstacles to reducing HIV spread, engagement in HIV treatment, and poor mental health functioning among people living with HIV (PLWH). Although disclosure is important for people to receive social support, the fear of stigma and discrimination prevents PLWH from disclosing their status. For children and adolescents growing up with HIV -with no opportunity for normal transition through adolescence due to stigma, it is important to identify additional family and community support systems, to improve their acceptance and health outcomes, including mental health functioning. This study examined family communication and social support factors associated with HIV disclosure and HIV-related stigma among children and adolescents living with HIV in Uganda. Baseline data from an NICHD-funded Suubi+Adherence study (N=702) were analyzed. Adolescents (10-16 years) were eligible to participate if they were: 1) HIV positive and knew their HIV status, 2) prescribed antiretroviral therapy, 3) lived within a family, not an institution, and 4) enrolled in one of the 39 health centers in the study area. Multiple regression analyses were conducted to determine family communication (frequency and level of comfort communicating with caregiver), social support (perceived child-caregiver support and social support from classmates, close friends, teachers, and caregivers), associated with HIV disclosure, disclosure comfort, and HIV internalized and anticipated stigma. Results show that level of comfort communicating with a caregiver was significantly associated with how often children discussed their HIV status with other people (B = 0.02, 95% CI = 0.00, 0.03, p = 0.04), and level of HIV disclosure comfort (B = 0.08, 95% CI = 0.04, 0.13, p < 0.01). In addition, support from within the school environment, i.e., from teachers and classmates, was uniquely associated with both HIV disclosure and HIV-related stigma. Findings point to schools as potential for implementing HIV stigma-reduction programs. In addition, programming aimed at improving HIV care and treatment outcomes for adolescents living with HIV should consider incorporating both family communication strengthening and HIV-stigma reduction strategies in their efforts, in order to improve HIV health-related outcomes, including overall mental health functioning of HIV positive adolescents.