The role of alcohol use in antiretroviral adherence among individuals living with HIV in South Africa: Event-level findings from a daily diary study

Stakeholder perspectives on the Kisoboka intervention: A behavioral and structural intervention to reduce hazardous alcohol use and improve HIV care engagement among men living with HIV in Ugandan fishing communities

BACKGROUND

East Africa's fishing communities experience a high burden of two interrelated and frequently co-occurring health issues: HIV and hazardous alcohol use. Nearly two-thirds of Ugandan fisherfolk men meet the criteria for harmful alcohol use. We developed a multilevel intervention to reduce hazardous alcohol use and improve HIV care engagement among fisherfolk men living with HIV (LWHIV) in Wakiso district, Uganda.

METHODS

This is a qualitative study of stakeholder perspectives on the appropriateness, acceptability, and feasibility of a multilevel intervention for fisherfolk men LWHIV. The proposed intervention, Kisoboka ("It is possible!"), combines a structural component [changing the mode of work payments from cash to mobile money] with a behavioral component [motivational interviewing-based counseling combined with content using behavioral economic principles to promote behavior change]. We conducted one focus group (n=7) and eight in-depth interviews with fisherfolk men LWHIV and 19 key informant (KI) interviews with health workers, employers, and community leaders. These explored the appropriateness, acceptability, and feasibility of specific key intervention components.

RESULTS

Overall, stakeholders' perspectives supported high intervention acceptability and perceived appropriateness of the proposed intervention. It was perceived to be feasible with some caveats of recommendations for overcoming potential implementation challenges identified (e.g., having a friend assist with documenting savings and alcohol use if an individual was unable to write themselves) which are discussed.

CONCLUSION

This work highlights the potential of the Kisoboka intervention and the importance of early engagement of key stakeholders in the intervention development process to ensure appropriateness, acceptability, feasibility, and socio-cultural fit.

The Relationship Between Harmful Alcohol Use and Antiretroviral Non-adherence in People Accessing HIV Treatment in Cape Town, South Africa: An Event-Level Analysis

Harmful alcohol consumption can significantly compromise adherence to antiretroviral therapy (ART). Prior research has identified aggregate relationships between alcohol use and ART non-adherence, largely relying on concurrent assessment of these domains. There is relatively limited evidence on more nuanced day-level associations between alcohol use and ART non-adherence, despite potentially important clinical implications. We recruited adults with HIV treatment adherence challenges and harmful alcohol use (n = 53) from HIV care in South Africa. We examined relationships between alcohol use and same and next day ART adherence, accounting for the role of weekends/holidays and participant demographics, including gender. Results demonstrated that ART adherence was significantly worse on weekend/holiday days. Next day adherence was significantly worse in the context of weekend alcohol use and among men. These results suggest the importance of tailoring intervention strategies to support ART adherence during weekend drinking and for men engaged in heavy episodic drinking.

Association Between ART Adherence and Mental Health: Results from a National HIV Sero-Behavioural Survey in South Africa

This paper assesses the levels of antiretroviral treatment (ART) adherence and mental health distress among study participants in a national behavioural HIV-sero prevalence study South Africa. The study was a cross-sectional population-based multi-stage stratified cluster random survey, (SABSSM V, 2017). Structured questionnaires were used to collect information on socio-demographics, HIV knowledge, perceptions, HIV testing and HIV treatment history. Study participants were tested for HIV infection, antiretroviral use, viral suppression, and ART drug resistance. A total of 2155 PLHIV aged 15 years or older who were on ART were included in the study. Incidence of either moderate or severe mental health distress was 19.7%. Self-reported ART adherence among study participants with no, mild, moderate, or severe mental distress was 82%, 83%, 86% and 78%, respectively. The adjusted odds ratio for ART non-adherence was 0.58 (95% CI 0.24; 1.40) for mild mental distress, 0.82 (95% CI 0.35; 1.91) for moderate mental distress and 2.19 (95% CI 1.14; 4.19) for severe mental distress groups compared to the no mental health distress group. The other factors that were associated with ART non-adherence in adjusted models included education level, alcohol use and province/region of residence. The study revealed that mental health remains a challenge to ART adherence in South Africa. To improve ART adherence, HIV continuum of care programs should include screening for mental health among people living with HIV.

A conceptual model of alcohol use and adherence to antiretroviral therapy: systematic review and theoretical implications for mechanisms of action

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

The Drinkers' Intervention to Prevent Tuberculosis (DIPT) trial among heavy drinkers living with HIV in Uganda: study protocol of a 2×2 factorial trial

Background

The risk of tuberculosis (TB) is high among people with HIV (PWH). Heavy alcohol drinking independently increases TB risk and approximately 25% of PWH globally engage in heavy drinking. While isoniazid (INH) preventive therapy decreases TB incidence and mortality among PWH, heavy drinking during INH is associated with liver toxicity and poor adherence. Interventions are, therefore, urgently needed to decrease alcohol use and improve adherence to INH in this population in settings with high prevalence of HIV and TB like Uganda.

Methods

The Drinkers’ Intervention to Prevent TB (DIPT) study is a 2×2 factorial randomized controlled trial among HIV/TB co-infected adults (≥18 years) who engage in heavy alcohol drinking and live in Uganda. The trial will allocate 680 participants with a 1:1:1:1 individual randomization to receive 6 months of INH and one of the following interventions: (1) no incentives (control), (2) financial incentives contingent on low alcohol use, (3) financial incentives contingent on high adherence to INH, and (4) escalating financial incentives for both decreasing alcohol use and increasing adherence to INH. Incentives will be in the form of escalating lottery-based monetary rewards. Participants will attend monthly visits to refill isoniazid medications, undergo liver toxicity monitoring, and, except for controls, determine eligibility for prizes. We will estimate (a) the effect of incentives contingent on low alcohol use on reduction in heavy drinking, measured via a long-term objective and self-reported metric of alcohol use, at 3- and 6-month study visits, and (b) the effect of incentives contingent on high adherence to INH, measured as >90% pill-taking days by medication event monitoring system cap opening. We will use qualitative methods to explore the mechanisms of any influence of financial incentives on HIV virologic suppression.

Discussion

This study will provide new information on low-cost strategies to both reduce alcohol use and increase INH adherence among people with HIV and TB infection who engage in heavy drinking in low-income countries with high HIV and TB prevalence.

Trial registration

ClinicalTrials.gov NCT03492216. Registered on April 10, 2018

Ineffective health control: concept analysis

OBJECTIVES

to identify and synthesize the concept of Ineffective Health Control.

METHODS

Concept Analysis from the perspective of Walker and Avant, operationalized by an integrative review in the databases Scopus, LILACS, PubMed, CINAHL, Web of Science, Science Direct e Cochrane, using the descriptors: Adhesion to Medication; Cooperation and Adherence to Treatment and Acquired Immunodeficiency Syndrome.

RESULTS

five critical attributes were identified for the concept, namely: patient's refusal to follow the therapeutic plan; abandoning treatment and worsening signs and symptoms; difficulty in reaching agreed goals; difficulty following health professionals' guidelines; multifactorial and dynamic process.

CONCLUSIONS

the concept of Ineffective Health Control is characterized by a multifactorial and dynamic process evidenced by the patient's refusal to follow a therapeutic plan, favouring the abandonment of treatment and resulting in the worsening of signs and symptoms and failure to reach goals.

Potential challenges to sustained viral load suppression in the HIV treatment programme in South Africa: a narrative overview

Background

South Africa, with one of the highest HIV prevalences in the world, introduced the universal test and treat (UTT) programme in September 2016. Barriers to sustained viral suppression may include drug resistance in the pre-treated population, non-adherence, acquired resistance; pharmacokinetics and pharmacodynamics, and concurrent use of alternative treatments.

Objective

The purpose of this review is to highlight potential challenges to achieving sustained viral load suppression in South Africa (SA), a major expectation of the UTT initiative.

Methodology

Through the PRISMA approach, published articles from South Africa on transmitted drug resistance; adherence to ARV; host genetic factors in drug pharmacokinetics and pharmacodynamics, and interactions between ARV and herbal medicine were searched and reviewed.

Results

The level of drug resistance in the pre-treated population in South Africa has increased over the years, although it is heterogeneous across and within Provinces. At least one study has documented a pre-treated population with moderate (> 5%) or high (> 15%) levels of drug resistance in eight of the nine Provinces. The concurrent use of ARV and medicinal herbal preparation is fairly common in SA, and may be impacting negatively on adherence to ARV. Only few studies have investigated the association between the genetically diverse South African population and pharmacokinetics and pharmacodynamics of ARVs.

Conclusion

The increasing levels of drug resistant viruses in the pre-treated population poses a threat to viral load suppression and the sustainability of first line regimens. Drug resistance surveillance systems to track the emergence of resistant viruses, study the burden of prior exposure to ARV and the parallel use of alternative medicines, with the goal of minimizing resistance development and virologic failure are proposed for all the Provinces of South Africa. Optimal management of the different drivers of drug resistance in the pre-treated population, non-adherence, and acquired drug resistance will be beneficial in ensuring sustained viral suppression in at least 90% of those on treatment, a key component of the 90-90-90 strategy.

Promoting Undetectable Equals Untransmittable in Sub-Saharan Africa: Implication for Clinical Practice and ART Adherence

In the last decade, reliable scientific evidence has emerged to support the concept that undetectable viral loads prevent human immunodeficiency virus (HIV). Undetectable equals untransmissible (U = U) is a simple message that everyone can understand. The success of this concept depends on strict adherence to antiretroviral therapy (ART) and the attainment of suppressed viral loads (VLs). To achieve U = U in sub-Saharan Africa (SSA), poor adherence to ART, persistent low-level viremia, and the emergence of drug-resistant mutants are challenges that cannot be overlooked. Short of a cure for HIV, U = U can substantially reduce the burden and change the landscape of HIV epidemiology on the continent. From a public health perspective, the U = U concept will reduce stigmatization in persons living with HIV (PLWHIV) in SSA and strengthen public opinion to accept that HIV infection is not a death sentence. This will also promote ART adherence because PLWHIV will aim to achieve U = U within the shortest possible time. This article highlights challenges and barriers to achieving U = U and suggests how to promote the concept to make it beneficial and applicable in SSA. This concept, if expertly packaged by policy-makers, clinicians, health service providers, and HIV control programs, will help to stem the tide of the epidemic in SSA.

Alcohol Use and Antiretroviral Therapy Non-Adherence Among Adults Living with HIV/AIDS in Sub-Saharan Africa: A Systematic Review and Meta-Analysis

Antiretroviral therapy (ART) is efficacious in improving clinical outcomes among people living with HIV (PLWH) and reducing HIV transmission when taken regularly. Research examining modifiable factors associated with ART non-adherence is critical for informing novel intervention development in settings with high HIV prevalence. Alcohol use has been linked with ART non-adherence in studies in sub-Saharan Africa; however, no review has pooled estimates across studies. We reviewed studies of alcohol use and ART non-adherence conducted in sub-Saharan Africa. We searched PubMed, CINAHL, EMBASE, and PsycINFO through August 2019 with terms related to ART non-adherence, alcohol use, and sub-Saharan Africa. One author reviewed titles/abstracts (n = 754) and two authors reviewed full texts (n = 308) for inclusion. Discrepancies were resolved by group consensus. Studies were retained if they quantitatively measured associations between alcohol use and ART non-adherence or viral non-suppression. We defined ART non-adherence using the definitions from each parent study (e.g., patients with > 5% missed ART doses during the previous four, seven or 30 days were considered non-adherent). A random effects meta-analysis was conducted to pool associations and we conducted additional analyses to assess between-study heterogeneity and publication bias and sensitivity analyses to determine robustness of our results when considering only certain study designs, alcohol use or ART scales, or studies that used viral non-suppression as their primary outcome. Of 56 articles meeting our inclusion criteria, 32 articles were included in the meta-analysis. All studies measured alcohol use via self-report. ART non-adherence was assessed using self-report, pill counts, or pharmacy records and definition of non-adherence varied depending on the measure used. Individuals who used alcohol had twice the odds of ART non-adherence compared with those who did not use alcohol (34% non-adherence among alcohol users vs. 18% among non-users; pooled odds ratio: 2.25; 95% confidence interval: 1.87-2.69; p < 0.001). We found evidence of a high degree of heterogeneity between studies (Cochrane Q statistic: 382.84, p< 0.001; I² proportion: 91.9%) and evidence of publication bias. However, the magnitude of our pooled odds ratio was consistent across a number of sensitivity analyses to account for heterogeneity and publication bias. In a secondary analysis with studies using viral non-suppression as their primary outcome, we also estimated a statistically significant pooled effect of alcohol use on viral non-suppression (pooled odds ratio: 2.47; 95% confidence interval: 1.58-3.87). Evidence suggests alcohol use is associated with ART non-adherence in Sub-Saharan Africa, potentially hindering achievement of the UNAIDS 90-90-90 HIV treatment targets.

Level and determinants of postpartum adherence to antiretroviral therapy in the Eastern Cape, South Africa

BACKGROUND

Adherence to antiretroviral therapy (ART), especially during the postpartum period, remains a major challenge in the efforts towards eliminating mother-to-child transmission of HIV. This study examined the levels and determinants of postpartum adherence to ART among mothers with HIV in the Eastern Cape, South Africa.

METHODS

In this cross-sectional analytical study, we interviewed 495 postpartum women with HIV between January and May 2018. We measured postpartum adherence using six questions probing participants' adherence behaviours since child birth. We categorised the adherence behaviours into complete adherence (mothers who reported no missed episode(s) of ART since child birth) and suboptimal adherence (mothers with any missed episode(s) of ART). Adjusted and unadjusted logistic regression models were used to examine the determinants of postpartum adherence to ART.

RESULTS

Overall, 63.9% reported complete adherence during the postpartum period but the rates varied by socio-demographic and behavioural characteristics. The adjusted logistic regression analysis showed that younger mothers were 70% less likely to report complete adherence to ART compared to mothers aged 40 and above. Likewise, mothers who currently use alcohol were 53% less likely to report complete postpartum adherence to ART compared to those who did not use alcohol. However, mothers who knew their partner's status were twice more likely to report complete postpartum adherence compared to those who did not. There was no statistically significant relationship between ART adherence and breastfeeding durations.

CONCLUSION

Postpartum adherence to ART is suboptimal in the study setting, and younger mothers and those who use alcohol have a lower odds of complete adherence. Knowing a partner's status improves adherence, but infant feeding practices did not influence postpartum adherence behaviours. It is critical to design and strengthen interventions which target young mothers and alcohol users. Also, HIV sero-status disclosure should be encouraged among mothers to facilitate partner support.

Alcohol-related beliefs and non-adherence to antiretroviral therapy in Cape Town, South Africa

The life-saving effects of antiretroviral therapy (ART) in treating HIV infection are compromised by alcohol use. A growing body of research shows that both unintentional (e.g., memory lapses) and intentional (e.g., forgoing ART to avoid mixing with alcohol) contribute to ART non-adherence. Beliefs that it is harmful to mix alcohol with ART (alcohol-ART interactive toxicity beliefs) contribute to intentional non-adherence, but their role in overall adherence is not clear. This study conducted a clinic-based survey with 100 men and 193 women (mean age = 36) to examine the prevalence of alcohol-ART interactive toxicity beliefs and whether they contribute to treatment non-adherence in South Africa. One in three (36%, n = 106) participants reported no current alcohol use and 64% (n = 187) reported current alcohol use. The majority of participants, including current alcohol drinkers, endorsed beliefs that it is harmful to mix ART and alcohol, with 57% who currently drink reporting that they forgo taking ART when they are drinking. Participants reported being warned not to mix alcohol and ART from family, friends, and health care providers. In addition, 62% of participants who do not drink, as well as 36% of those who do drink, tell others not to mix alcohol and ART. Mediation modelling found that alcohol use directly predicts ART adherence, and that this relationship is partially mediated by alcohol-ART interactive toxicity beliefs. Health care providers can play a critical role in disputing interactive toxicity beliefs and encouraging patients to take ART even when they are drinking.

Health benefits of positive reappraisal coping among people living with HIV/AIDS: A systematic review

People living with HIV/AIDS (PLWHA) often face significant stress, ranging from perceiving identity changes to encountering barriers to daily health behavior engagement. To manage these experiences, many people use positive reappraisal coping (including benefit finding and perceiving growth). Effective coping is highly important for PLWHA; stress reduction has salutary effects on multiple indicators of health. The present systematic review, conducted in PubMed, PsycINFO, and CINAHL, synthesises findings from 33 studies of PLWHA, addressing effects of positive reappraisal on health-related outcomes for adults living with HIV as a chronic illness. Studies were evaluated based on methodological considerations, measurement of key variables, and implications for specific aspects of health. Results suggest that positive reappraisal is often beneficial when dealing with the implications of a potentially traumatic HIV diagnosis on one's identity, although effects may be contextually bound. Implications of these findings are reviewed, emphasizing the importance of positive reappraisal for enhancing health promotion and self-management of HIV. Although the present review is limited by inclusion of multiple disparate outcomes and exclusion of non-English-language articles, these findings inform a comprehensive model of direct and indirect effects of positive reappraisal on emotional, functional, physiological, and behavioural aspects of health useful for guiding future research.

Substance use and its effect on antiretroviral treatment adherence among male fisherfolk living with HIV/AIDS in Uganda

Background

Fisherfolk are a most-at-risk population for HIV being prioritized for the scale up of HIV treatment in Uganda. Heavy alcohol use and potential drug use may be a major barrier to treatment adherence for men in this setting.

Objective

This study examines the prevalence of substance use, and its influence on antiretroviral treatment (ART) adherence, among male fisherfolk on ART in Wakiso District, Uganda.

Methods

This cross-sectional study included structured questionnaires (N = 300) with men attending HIV clinics near Lake Victoria. Using generalized logistic modeling analyses with a binomial distribution and logit link, we conducted multivariate models to test the association between each alcohol variable (quantity and frequency index, hazardous drinking) and missed pills, adjusting for covariates, and tested for interactions between number of pills prescribed and alcohol variables.

Results

Thirty-one percent of men reported sub-optimal adherence. Half (46.7%) reported drinking, of which 64.8% met criteria for hazardous drinking. Illicit drug use was low (6%). In the multivariate model, men with greater scores on the alcohol frequency and quantity index were more likely to report missed pills compared to those reporting no drinking (AOR: 1.60, 95% CI: 1.29–1.97). Hazardous drinking had a greater effect on missed ARV doses among men taking twice daily regimens compared to once daily (AOR: 4.91, 95% CI: 1.68–14.37).

Conclusions

Our findings highlight the need for targeted alcohol-reduction interventions for male fisherfolk on ART who drink at high quantities to improve ART adherence and to prevent the known negative health effects of alcohol for HIV-infected individuals.

Alcohol Use and HIV Disease Progression in an Antiretroviral Naive Cohort

BACKGROUND

Alcohol use has been shown to accelerate disease progression in experimental studies of simian immunodeficiency virus in macaques, but the results in observational studies of HIV have been conflicting.

METHODS

We conducted a prospective cohort study of the impact of unhealthy alcohol use on CD4 cell count among HIV-infected persons in southwestern Uganda not yet eligible for antiretroviral treatment (ART). Unhealthy alcohol consumption was 3-month Alcohol Use Disorders Identification Test-Consumption positive (≥3 for women, ≥4 for men) and/or phosphatidylethanol (PEth-an alcohol biomarker) ≥50 ng/mL, modeled as a time-dependent variable in a linear mixed effects model of CD4 count.

RESULTS

At baseline, 43% of the 446 participants were drinking at unhealthy levels and the median CD4 cell count was 550 cells/mm (interquartile range 416-685). The estimated CD4 cell count decline per year was -14.5 cells/mm (95% confidence interval: -38.6 to 9.5) for unhealthy drinking vs. -24.0 cells/mm (95% confidence interval: -43.6 to -4.5) for refraining from unhealthy drinking, with no significant difference in decline by unhealthy alcohol use (P value 0.54), adjusting for age, sex, religion, time since HIV diagnosis, and HIV viral load. Additional analyses exploring alternative alcohol measures, participant subgroups, and time-dependent confounding yielded similar findings.

CONCLUSION

Unhealthy alcohol use had no apparent impact on the short-term rate of CD4 count decline among HIV-infected ART naive individuals in Uganda, using biological markers to augment self-report and examining disease progression before ART initiation to avoid unmeasured confounding because of misclassification of ART adherence.

Multi-level Determinants of Clinic Attendance and Antiretroviral Treatment Adherence Among Fishermen Living with HIV/AIDS in Communities on Lake Victoria, Uganda

This cross-sectional study assessed determinants of HIV clinic appointment attendance and antiretroviral treatment (ART) adherence among 300 male fisherfolk on ART in Wakiso District, Uganda. Multi-level factors associated with missed HIV clinic visits included those at the individual (age, AOR = 0.98, 95% CI 0.97-0.99), interpersonal (being single/separated from partner, AOR: 1.25, 95% CI 1.01-1.54), normative (anticipated HIV stigma, AOR: 1.55, 95% CI 1.05-2.29) and physical/built environment-level (travel time to the HIV clinic, AOR: 1.11, 95% CI 1.02-1.20; structural-barriers to ART adherence, AOR: 1.27, 95% CI 1.04-1.56; accessing care on a landing site vs. an island, AOR: 1.35, 95% CI 1.08-1.67). Factors associated with ART non-adherence included those at the individual (age, β: - 0.01, η2 = 0.03; monthly income, β: - 0.01, η2 = 0.02) and normative levels (anticipated HIV stigma, β: 0.10, η2 = 0.02; enacted HIV stigma, β: 0.11, η2 = 0.02). Differentiated models of HIV care that integrate stigma reduction and social support, and reduce the number of clinic visits needed, should be explored in this setting to reduce multi-level barriers to accessing HIV care and ART adherence.

The Role of Religious Service Attendance, Psychosocial and Behavioral Determinants of Antiretroviral Therapy (ART) Adherence: Results from HPTN 063 Cohort Study

Early and sustained antiretroviral therapy (ART) adherence can suppress the HIV virus in individuals and reduce onward transmission of HIV in the population. Religiosity has been associated with better HIV clinical outcomes. Data are from a longitudinal, observational study of 749 HIV-infected individuals from Brazil, Zambia, and Thailand (HPTN 063). Ordered logistic regression assessed whether religious service attendance was associated with ART adherence (self-reported and plasma HIV-RNA) and moderated the association between alcohol problems and ART adherence. In each country, > 80% of participants reported high self-reported ART adherence (good/very good/excellent). Religious service attendance exceeded 85% but was statistically unrelated to adherence. In combined-country models, (p = 0.03) as alcohol problems increased, the probability of high self-reported ART adherence, as well as viral-load, became weaker at higher compared to low service attendance frequency. Future studies should evaluate spirituality variables and replicate the moderation analyses between religious attendance and alcohol problems.

Couple Interdependence Impacts Alcohol Use and Adherence to Antiretroviral Therapy in Malawi

In sub-Saharan Africa, harmful alcohol use among male drinkers is high and has deleterious consequences on adherence to antiretroviral therapy (ART), HIV clinical outcomes, and couple relationship dynamics. We conducted in-depth qualitative interviews with 25 Malawian couples on ART to understand how relationships influence adherence to ART, in which alcohol use emerged as a major theme. Almost half of men (40%) reported current or past alcohol use. Although alcohol use was linked to men's non-adherence, women buffered this harm by encouraging husbands to reduce alcohol use and by offering adherence support when men were drinking. Men's drinking interfered with being an effective treatment guardian for wives on ART and also weakened couple support systems needed for adherence. Relationship challenges including food insecurity, intimate partner violence, and extramarital relationships appeared to exacerbate the negative consequences of alcohol use on ART adherence. In this setting, alcohol may be best understood as a couple-level issue. Alcohol interventions for people living with HIV should consider approaches that jointly engage both partners.

A qualitative study on alcohol consumption and HIV treatment adherence among men living with HIV in Ugandan fishing communities

Ugandan fishing communities are dually burdened with high rates of HIV and alcohol use. This qualitative study explores context and motivation of alcohol consumption, and alcohol's effect on antiretroviral treatment (ART) adherence, among male fisherfolk living with HIV in Wakiso District, Uganda. We conducted in-depth semi-structured interviews with 30 men in HIV care and on ART, and used a thematic analysis approach for analysis. Alcohol use was identified as a major barrier to ART adherence through cognitive impairment and the intentional skipping of doses when drinking. Men reportedly reduced their drinking since HIV diagnosis - motivated by counseling received from providers and a newfound desire to live a healthy lifestyle. However, social, occupational, and stress-related influences that make alcohol reduction difficult were identified. Our findings suggest alcohol use may pose a challenge to ART adherence for fishermen living with HIV - and has implications for the tailoring of screening and brief intervention for alcohol reduction in HIV care for this population.

Why do people living with HIV not initiate treatment? A systematic review of qualitative evidence from low- and middle-income countries

BACKGROUND

Many people living with HIV (PLWH) who are eligible for antiretroviral therapy (ART) do not initiate treatment, leading to excess morbidity, mortality, and viral transmission. As countries move to treat all PLWH at diagnosis, it is critical to understand reasons for non-initiation.

METHODS

We conducted a systematic review of the qualitative literature on reasons for ART non-initiation in low- and middle-income countries. We screened 1376 titles, 680 abstracts, and 154 full-text reports of English-language qualitative studies published January 2000-April 2017; 20 met criteria for inclusion. Our analysis involved three steps. First, we used a "thematic synthesis" approach, identifying supply-side (facility) and demand-side (patient) factors commonly cited across different studies and organizing these factors into themes. Second, we conducted a theoretical mapping exercise, developing an explanatory model for patients' decision-making process to start (or not to start) ART, based on inductive analysis of evidence reviewed. Third, we used this explanatory model to identify opportunities to intervene to increase ART uptake.

RESULTS

Demand-side factors implicated in decisions not to start ART included feeling healthy, low social support, gender norms, HIV stigma, and difficulties translating intentions into actions. Supply-side factors included high care-seeking costs, concerns about confidentiality, low-quality health services, recommended lifestyle changes, and incomplete knowledge of treatment benefits. Developing an explanatory model, which we labeled the Transdisciplinary Model of Health Decision-Making, we posited that contextual factors determine the costs and benefits of ART; patients perceive this context (through cognitive and emotional appraisals) and form an intention whether or not to start; and these intentions may (or may not) be translated into actions. Interventions can target each of these three stages.

CONCLUSIONS

Reasons for not starting ART included consistent themes across studies. Future interventions could: (1) provide information on the large health and prevention benefits of ART and the low side effects of current regimens; (2) reduce stigma at the patient and community levels and increase confidentiality where stigma persists; (3) remove lifestyle requirements and support patients in integrating ART into their lives; and (4) alleviate economic burdens of ART. Interventions addressing reasons for non-initiation will be critical to the success of HIV "treat all" strategies.

Hazardous alcohol consumption and alcohol-related problems are associated with unknown and HIV-positive status in fishing communities in Uganda

In Uganda, alcohol consumption is associated with higher HIV prevalence. However, research is needed to better understand how different patterns of alcohol consumption and alcohol-related problems may drive this association. In this cross-sectional study, we examined how hazardous alcohol use and alcohol-related problems such as psychological, physical, and social harms are associated with HIV status in fishing communities in Uganda. 300 (132 male, 168 female) residents of fishing communities in Uganda (75 participants from each of the following occupational groups: fishmongers, alcohol sellers, commercial sex workers (CSW), and fishermen) completed an interviewer-assisted computerized interview. We captured information on sociodemographics and HIV testing history. Prior 12-month hazardous alcohol consumption patterns and alcohol-related problems were assessed with the AUDIT and AUDADIS. 19.7%, 58.0%, and 23.3% of the sample reported being HIV positive, being HIV negative from a test within the prior 12 months, and not knowing their HIV status respectively. 18.7% reported the co-occurrence of hazardous alcohol consumption patterns and alcohol-related problems. 7.7% reported either hazardous alcohol consumption patterns or alcohol-related problems. Compared to non-drinkers, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of being HIV positive (adjOR 2.75, 95% CI 1.17-6.43) and of unknown HIV status (adjOR 3.35, 95% CI 1.52-7.42). Reporting only hazardous consumption levels, only alcohol-related problems, or low-risk drinking, did not increase the odds of being HIV positive or of unknown status. Among those not HIV positive, those with co-occurring hazardous consumption and alcohol-related problems had greater odds of never having had an HIV test (adjOR 3.78, 95% CI 1.63-8.68). The co-occurrence of hazardous alcohol use and alcohol related problems appears to be a prominent risk factor for HIV infection, not knowing one's HIV status, and never testing for HIV in this setting.

Depressive Symptoms, Disclosure, HIV-Related Stigma, and Coping Following HIV Testing Among Outpatients in Uganda: A Daily Process Analysis

As efforts to end the HIV epidemic accelerate there is emphasis on reaching those living with undiagnosed HIV infection. Newly diagnosed individuals face a number of psychosocial challenges, yet we know little about depressive symptoms in the weeks immediately following diagnosis and how disclosure, coping, and other factors may affect short and longer-term depressive symptoms. Purposively sampled Ugandan outpatients completed structured interviews immediately prior to testing for HIV, daily for 28 days after receiving their test results, and at 3 and 6 months post-test. The sample included a total of 244 participants: 20 who tested HIV positive at baseline and who provided 342 daily data points, and 224 who tested HIV negative at baseline and who provided 4388 daily data points. We used linear mixed effects modeling to examine changes in depressive symptom scores over the 28 day daily interview period and predictors of depressive symptom scores and changes over time. Results from the mixed modeling revealed that while those diagnosed with HIV showed initially high depressive symptoms following diagnosis, their symptoms decreased significantly and on average fell below the cutoff for possible depression approximately 15 days after diagnosis. Among those who tested HIV-negative, on average their depressive symptoms were below the cutoff for possible depression and did not change over time. Among those diagnosed with HIV, disclosure, especially to a partner, on a particular day was associated with higher depressive symptoms that day. However, those who disclosed to their partner during the 28 days after diagnosis had significantly lower depression scores by the end of the 28 days as well as lower depression scores 3 and 6 months after diagnosis than did those who did not disclose to their partner during the 28 days after diagnosis. Scoring higher on HIV-related stigma on a particular day was associated with higher depressive symptoms that day and engaging in positive coping on a particular day was associated with lower depressive symptoms that day. Positive coping also accelerated the decrease in depressive symptoms over time. These data underscore the importance of timely disclosure to partners and suggest that regular depression screening after diagnosis and provision of mental health services could improve HIV care engagement and treatment outcomes.