"Not on the agenda": A qualitative study of influences on health services use among poor young women who use drugs in Cape Town, South Africa

Associations between childbirth, gang exposure and substance use among young women in Cape Town, South Africa

The prevalence and influence of gangs on adolescents and young adults remain a concern in Western Cape, South Africa-particularly as they have one of the largest gang presence. While less attention has been focused on young women, there is a need to elucidate the relationship between gang exposure and health behaviors, such substance use, in addition to understanding whether becoming a caregiver impacts this relationship. This study uses baseline data from 496 participants enrolled in a NIDA-funded R01 trial that recruited young women aged 16 to 19 who were out of school and reported recent alcohol or other drug use and sexual risk behavior. At enrollment, a risk behavior survey was administered, and urine drug screening was conducted. Multivariable logistic regression analyses were conducted to examine baseline associations between childbirth, a gang exposure index based on eight items, and positive drug screens of the most prevalent drugs in the Western Cape (marijuana, methaqualone, and methamphetamine). At enrollment, approximately 39% of the sample had a positive urine screen for marijuana, 17% for methaqualone, and 11% for methamphetamine. Additionally, 28% had ever given birth. While only 6% reported ever being a member of a gang, most reported exposure to gangs through their physical and social environments. For all three drugs, gang exposure was associated with statistically significantly higher odds of a positive screen. Every one-point increase in the gang exposure index was associated with a 31% increase in the odds of a positive marijuana screen (p < .001), a 26% increase for methaqualone (p = 0.005) and a 37% increase in the odds of a positive methamphetamine screen (p < .001). Ever given birth was associated with lower odds of marijuana use (adjusted odds ratio [AOR]: 0.63; 95% CI: 0.42-0.96), but it was not associated with methaqualone or methamphetamine use. The findings suggest that exposure to gangs through young women's social and physical environment is positively associated with drug use. Childbirth was also protective for marijuana use, indicating there may be something unique about this type of drug, such as one's ability to more easily stop use. Although very few young women reported gang membership, a majority reported some exposure, indicating the need to address how pervasive this exposure is and the potential risk.

Multilevel strategies to end HIV for young couples in Cape Town: Study protocol for a cluster randomized trial

This protocol presents a multilevel cluster randomized study in 24 communities in Cape Town, South Africa. The study comprises four specific aims. Aim 1, conducted during the formative phase, was to modify the original Couples Health CoOp (CHC) intervention to include antiretroviral therapy/pre-exposure prophylaxis (ART/PrEP), called the Couples Health CoOp Plus (CHC+), with review from our Community Collaborative Board and a Peer Advisory Board. Aim 1 has been completed for staging the trial. Aim 2 is to evaluate the impact of a stigma awareness and education workshop on community members' attitudes and behaviors toward young women and men who use AODs and people in their community seeking HIV services (testing/ART/PrEP) and other health services in their local clinics. Aim 3 is to test the efficacy of the CHC+ to increase both partners' PrEP/ART initiation and adherence (at 3 and 6 months) and to reduce alcohol and other drug use, sexual risk and gender-based violence, and to enhance positive gender norms and communication relative to HIV testing services (n = 480 couples). Aim 4 seeks to examine through mixed methods the interaction of the stigma awareness workshop and the CHC+ on increased PrEP and ART initiation, retention, and adherence among young women and their primary partners. Ongoing collaborations with community peer leaders and local outreach staff from these communities are essential for reaching the project's aims. Additionally, a manualized field protocol with regular training, fidelity checks, and quality assurance are critical components of this multilevel community trial for successful ongoing data collection. Trial registration. Clinicaltrials.gov Registration Number: NCT05310773. Pan African Trials: pactr.samrc.ac.za/ Registration Number: PACTR202205640398485.

Association between socioeconomic and motherhood characteristics with receiving community-based treatment services among justice-involved young female drug users: a retrospective cohort study in Taiwan

BACKGROUND

Drug-involved individuals who contact treatment services in Taiwan are mostly driven by criminal justice systems either as an alternative or adjunct to criminal sanctions for a drug offence. With a focus on justice-involved young female drug users, the present study examines the extent to which socioeconomic and motherhood characteristics are associated with receiving deferred prosecution, a scheme diverting drug offenders to community-based addiction treatment.

METHODS

We identified a cohort of 5869 women under the age of 30 arrested for using Schedule II drugs (primarily amphetamine-like stimulants) from the 2011-2017 National Police Criminal Records in Taiwan. Information concerning socioeconomic characteristics, pregnancy and live birth history, and deferred prosecution was obtained through linkage with the 2006-2019 National Health Insurance, birth registration, and deferred prosecution datasets. Multinomial logistic regression was used to evaluate the association with stratification by recidivism status.

RESULTS

Within six months of arrest, 21% of first-time offenders (n = 2645) received deferred prosecution and 23% received correction-based rehabilitation; the corresponding estimates for recidivists (n = 3224) were 6% and 15%, respectively. Among first-time offenders, low/unstable income was associated with lower odds of deferred prosecution (adjusted odds ratio [aOR] = 0.71; 95% CI: 0.58, 0.88). For recidivists, those with low/unstable income (aOR = 1.58) or unemployment (aOR = 1.58) had higher odds of correction-based rehabilitation; being pregnant at arrest was linked with reduced odds of deferred prosecution (aOR = 0.31, 95% CI: 0.13, 0.71) and correction-based rehabilitation (aOR = 0.50, 95% CI: 0.32, 0.77).

CONCLUSIONS

For the young women arrested for drug offences, disadvantaged socioeconomic conditions were generally unfavored by the diversion to treatment in the community. Childbearing upon arrest may lower not only the odds of receiving medical treatment but also correctional intervention. The criminal prosecution policy and process should be informed by female drug offenders' need for treatment and recovery.

"You have to drink with a little bit of shame": Alcohol and other drug use among young people from migrant and ethnic minority backgrounds in Melbourne, Australia

Migrant and ethnic minority groups are underrepresented in alcohol and other drug (AOD) research. This qualitative study explored AOD use among young people from migrant and ethnic minority backgrounds in Melbourne, Australia. We conducted one focus group and 16 interviews and thematically analyzed data drawing on the social-ecological model of health. Theme one showed AOD use was considered a "normal" part of youth identity, particularly for participants who had grown up with peer groups in Australia. Theme two highlighted participant's sense of responsibility to meet expectations and make informed decisions about AOD use to protect themselves and their friends. Theme three highlighted participant's risk of experiencing AOD-related stigma through negative stereotypes and fear of consequences within families and communities, particularly among female participants. Participants' perceptions and experiences differed by individual factors, interpersonal relationships, AOD accessibility across settings and broader gender, cultural and religious norms. Interventions developed with young people from migrant and ethnic minority backgrounds are needed to target the social-ecological factors underpinning AOD use, particularly stigma.

Residential and inpatient treatment of substance use disorders in Sub-Saharan Africa: a scoping review

BACKGROUND

With substance use rates increasing in Sub-Saharan Africa (SSA), an understanding of the accessibility and effectiveness of rehabilitative services for people who use alcohol and other drugs (AOD) is critical in the global efforts to diagnose and treat substance use disorders (SUD). This scoping review seeks to address the gaps in knowledge related to the types of research that have been conducted regarding inpatient or residential SUD treatment in SSA, the settings in which the research was conducted, and the study countries.

METHODS

A search of three databases, PubMED, Scopus, and African Index Medicus, was conducted for publications related to the treatment of SUD in inpatient or residential settings in SSA. Articles were screened at the title/abstract level and at full text by two reviewers. Articles eligible for inclusion were original research, conducted in SSA, published in English, included populations who received or were currently receiving treatment for SUD in inpatient or residential settings, or documented demand for SUD services.

RESULTS

This scoping review included 82 studies originating from 6 countries in SSA. Three themes emerged within the literature: access and demand for inpatient and residential SUD treatment, quality and outcomes of SUD treatment, and descriptions of the services offered and staffing of these facilities. Barriers to access include financial barriers, limited availability of services, and geographic concentration in cities. Women were shown to access residential and inpatient SUD treatment at lower rates than men, and certain racial groups face unique language and financial barriers in accessing services. Studies indicate mixed success of inpatient and residential SUD treatment in sustained SUD remission for patients.

CONCLUSION

There are significant gaps in the literature, driven by a lack of longitudinal studies focused on patient outcomes following treatment and the use of a narrow definition of treatment success. Both structural and non-structural barriers, such as stigma and discrimination, are barriers to access. Further research is needed to evaluate approaches to mitigate these barriers and expand access to residential and inpatient SUD treatment.

Outcomes of substance use and sexual power among adolescent girls and young women in Cape Town: Implications for structural and cultural differences

Adolescent girls and young women (AGYW) in South Africa experience contextual barriers to HIV risk reduction including incomplete schooling, unintended pregnancy, substance use, and gender-based violence. A cluster randomised trial in Cape Town allocated 24 Black and Coloured communities to a gender-focused HIV risk-reduction intervention or HIV testing, with 500 AGYW total enrolled. We evaluated intervention efficacy by comparing mean differences overall, by community population group (Black and Coloured) and among those with structural barriers based on neighbourhood, education, and employment (n = 406). Both arms reported reductions in alcohol, cannabis, and condomless sex, with no intervention efficacy overall. Among AGYW with barriers, intervention participants reported fewer days of methamphetamine use at 6 months (t(210) = 2·08, p = ·04). In population group analysis, we found intervention effects on alcohol and sexual communication. Intervention participants in Black communities had fewer days of alcohol use at 12 months (t(136) = 2·10, p = ·04). Sexual discussion (t(147) = -2·47, p = ·02) and condom negotiation (t(146) = -2·51, p = ·01) increased for intervention participants at 12 months in Coloured communities. Gender-focused interventions must address population group differences and intersecting barriers to decrease substance use and increase education, skills, and sexual health protection.

Community-based counselling programme for pregnant women with alcohol problems in Cape Town, South Africa: a qualitative study of the views of pregnant women and healthcare professionals

Introduction

South Africa lacks services to detect and address alcohol use during pregnancy, particularly outside of health-care facilities. This study aimed to explore pregnant women and healthcare providers' perceptions of the acceptability, feasibility and appeal of a community-based counselling programme for pregnant women with alcohol problems.

Methods

Twenty-eight in-depth interviews with pregnant women who drink, Community Health Workers (CHWs) and antenatal service providers were conducted. Transcribed interviews were analyzed thematically using a combined deductive and inductive approach.

Results

Women reported feeling uncomfortable seeking help for their alcohol use at antenatal clinics, limiting usefulness of current support services. All stakeholders perceived a community-based intervention to be acceptable and feasible as it could be integrated with other CHW-delivered services. Participants thought an intervention should facilitate early linkage to antenatal services and should include partners or family members. The feasibility of an intervention may depend on the relationship between CHWs and clinic-based antenatal staff, and their relationships with pregnant women. Clinic and community challenges to implementation were raised. Clinic-level challenges included shortage of space, staff capacity, high number of pregnant women, long waiting times, financial burden of having to travel to a clinic, lack of comfort and privacy and staff attitudes. Community-level challenges included crime, lack of privacy, lack of attention given competing interests in the home, fear due to abuse, and stigma and discrimination from other community members. Suggestions for overcoming these challenges were provided.

Conclusion

Findings provide essential information to facilitate the adaptation of a community-based alcohol counselling programme for greater acceptability, feasibility and cultural appropriateness for the South African context. Intensive training, supervision and support is required to ensure the programme is delivered as planned.

Symptoms of posttraumatic stress partially mediate the relationship between gender-based violence and alcohol misuse among South African women

BACKGROUND

The association of traumatic experiences with problematic alcohol use has been described, but data on possible mediation effects of mental distress are sparse. We examined whether mental ill-health mediated the association between trauma exposure across the lifespan and alcohol use.

METHOD

We analysed cross-sectional data from a sample of rape-exposed and non-rape-exposed women, living in KwaZulu-Natal, with self-reported data on alcohol misuse (AUDIT-C cut-off ≥ 3) and exposure to childhood maltreatment (CM), intimate partner violence (IPV), non-partner sexual violence (NPSV), other traumatic events, and mental ill-health. Logistic regression and multiple mediation models were used to test the mediation effects of symptoms of depression and PTSS on the association between abuse/trauma and alcohol misuse.

RESULTS

Of 1615 women, 31% (n = 498) reported alcohol misuse. Exposure to any CM (adjusted odds ratio (aOR): 1.59, 95% confidence interval (CI): 1.27-1.99), as well as to sexual, physical and emotional CM, were independently associated with alcohol misuse. Lifetime exposure to any IPV (aOR:2.01, 95%CI:1.59-2.54), as well as to physical, emotional and economic IPV, NPSV (aOR: 1.75, 95%CI: 1.32-2.33), and other trauma (aOR:2.08, 95%CI:1.62-2.66), was associated with alcohol misuse. Exposure to an increasing number of abuse types, and other traumatic events, was independently associated with alcohol misuse. PTSS partially mediated the associations of CM, IPV, NPSV and other trauma exposures with alcohol misuse (ps ≤ 0.04 for indirect effects), but depression symptoms did not.

CONCLUSIONS

These findings highlight the need for trauma-informed interventions to address alcohol misuse that are tailored to the needs of women who have experienced violence.

Prevalence of depression, syndemic factors and their impact on viral suppression among female sex workers living with HIV in eThekwini, South Africa

INTRODUCTION

Over half of female sex workers (FSW) in South Africa are living with HIV and clinical depression has been frequently documented among FSW. Data characterizing structural determinants of depression and the role of syndemic theory, synergistically interacting disease states, on viral suppression among FSW in South Africa are limited.

METHODS

Between July 2018-March 2020, non-pregnant, cisgender women (≥ 18 years), reporting sex work as their primary income source, and diagnosed with HIV for ≥ 6 months were enrolled into the Siyaphambili trial in eThekwini, South Africa. Using baseline data, robust Poisson regression models were used to assess correlates of depression and associations between depression and syndemic factors on viral suppression.

RESULTS

Of 1,384 participants, 459 (33%) screened positive for depression, defined as a score of ≥ 10 on the PHQ-9. Physical and sexual violence, drug use, alcohol use, anticipated stigma and internalized stigma were univariately associated with depression (all p's < 0.05) and included the multivariate model. In the multivariate regression, prevalence of depression was higher among participants experiencing sexual violence (PR = 1.47 95% CI:1.24,1.73), physical violence 5 times or more in < 6 months (PR = 1.38 95% CI:1.07, 1.80), using illicit drugs in the last month (PR = 1.23 95%:CI 1.04, 1.48), and reporting higher levels of internalized stigma (PR = 1.11, 95% CI:1.04,1.18). Depression in the absence of the Substance Abuse, Violence and AIDS SAVA syndemic factors was associated with increased prevalence of unsuppressed viral load (aPR 1.24; 95% CI:1.08,1.43), and the SAVA substance use and violence syndemic was associated with an increase in unsuppressed viral load among non-depressed FSW (aPR 1.13; 95% CI:1.01, 1.26). Compared to those experiencing neither factors, those jointly experiencing depression and the SAVA syndemics were at increased risk for unsuppressed viral load (aPR 1.15; 95% CI:1.02,1.28).

CONCLUSION

Substance use, violence, and stigma were all associated with depression. Depression and syndemic factors (substance use + violence) were related to unsuppressed viral load; we did not observe higher unsuppressed viral load amongst those experiencing both depression and syndemic factors. Our findings point to the need to understand the unmet mental health needs of FSW living with HIV.

TRIAL REGISTRATION

Clinical Trial Number: NCT03500172.

Social Determinants of Seeking and Reaching Injury Care in South Africa: A Community-Based Qualitative Study

Background

Timely access to quality injury care saves lives and prevents disabilities. The impact of social determinants of health on the high injury prevalence in South Africa is well documented, however, evidence of their role in accessing injury care is lacking. This study explored the social determinants of seeking and reaching injury care in South Africa.

Methods

This was a qualitative study involving rural and urban patients, community members, and healthcare providers in Western Cape, South Africa. Data were obtained through semi-structured interviews and focus group discussions using an interview guide informed by the four-delays framework. Inductive and deductive approaches were used for thematic analysis.

Results

A total of 20 individual interviews and 5 focus group discussions were conducted. There were 28 males (individual interviews: 13; focus groups: 15) and 22 females (individual interviews: 7; focus groups: 15), and their mean age was 41 (standard deviation ±15) years. Barriers to seeking and reaching injury care cut across five social determinants of health domains: healthcare access and quality; neighbourhood and environment; social and community context; education; and economic stability. The most prominent social determinants of seeking and reaching injury care were related to healthcare access and quality, including perceived poor healthcare quality, poor attitude of healthcare workers, long waiting time, and ambulance delays. However, there was a strong interconnection between these and neighbourhood and environmental determinants such as safety concerns, high crime rates, gangsterism, lack of public transportation, and social and community factors (presence/absence of social support and alcohol use). Barriers related to education and economic stability were less prevalent.

Conclusion

We found a substantial role of neighbourhood, social, and community factors in seeking and reaching injury care. Therefore, efforts aimed at improving access to injury care and outcomes must go beyond addressing healthcare factors to include other social determinants and should involve collaborations with multiple sectors, including the community, the police, the transport department, and alcohol regulation agencies.

A scoping review of how exposure to urban violence impacts youth access to sexual, reproductive and trauma health care in LMICs

Violence in the community can impact access to health care. This scoping review examines the impact of urban violence upon youth (aged 15-24) access to sexual and reproductive health and trauma care in Low and Middle Income Countries (LMICs). We searched key electronic health and other databases for primary peer-reviewed studies from 2010 through June 2020. Thirty five of 6712 studies extracted met criteria for inclusion. They were diverse in terms of study objective and design but clear themes emerged. First, youth experience the environment and interpersonal relationships to be violent which impacts their access to health care. Second, sexual assault care is often inadequate, and stigma and abuse are sometimes reported in treatment settings. Third is the low rate of health seeking among youth living in a violent environment. Fourth is the paucity of literature focusing on interventions to address these issues. The scoping review suggests urban violence is a structural and systemic issue that, particularly in low-income areas in LMICs, contributes to framing the conditions for accessing health care. There is a gap in evidence about interventions that will support youth to access good quality health care in complex scenarios where violence is endemic.

Putting out the welcome mat-A qualitative exploration of service delivery processes and procedures as barriers to treatment-seeking for people who use alcohol and other drugs

INTRODUCTION

There are a range of models and structures that determine features of alcohol and other drug treatment. Despite some structures being long-established, less is known about how specific aspects of service delivery impact treatment-seeking for people who use alcohol and other drugs. This Australian qualitative study explored both people with lived experience of problematic alcohol and other drug use, and health care staff's experiences of service delivery.

METHODS

Thirty-nine semi-structured interviews with people with lived experience and staff from either alcohol and other drug specialist, or broader health-care services, explored experiences of service delivery processes and procedures. Transcripts were thematically analysed and guided by a broad interest in barriers to treatment-seeking.

RESULTS

Within alcohol and other drug specialist services (i) time spent on wait lists; and (ii) poor implementation of assessment processes were identified barriers to treatment-seeking and engagement. Within broader health-care services (i) organisational expectations around behaviour and engagement; (ii) alcohol and other drugs viewed as separate to service role; and (iii) limited opportunities to informally engage were identified barriers to treatment-seeking.

DISCUSSION AND CONCLUSIONS

Results suggest opportunities to engage and undertake needs-based care planning are yet to be fully realised, particularly at the intake and assessment stages of alcohol and other drug service delivery; with frequent reassessment resulting in people repeatedly recounting traumatic experiences, often to different people, only to be placed back on wait lists with no support. Within broader health-care services aspects of service delivery may perpetuate stigma that places such people outside the purview of health care.

Structural violence and barriers to pain management during an opioid crisis: accounts of women who use drugs in Nigeria

Chronic pain management among marginalised populations have been extensively researched in North America, particularly amidst the opioid crisis. But little published research exists on this subject from Africa. This study explored experiences and management of chronic pain among marginalised women in the context of regulation of opioid prescribing using data from 16 qualitative interviews with women who use drugs (WWUD) in Uyo, Nigeria. Chronic pain was exacerbated by structural and everyday violence that acted to marginalise women and create a context of risk for inadequately managed pain. Participants experienced difficulty accessing biomedical pain management due to structural and systemic barriers, including cost, restrictions on opioid prescribing, stigma and other discriminatory practices, communication barriers and lack of social support. Restrictions on opioid prescribing and systemic discriminations against marginalised WWUD encouraged reliance on informal sources for falsified and substandard medications for pain treatment, which increased the risk of harm. Findings highlight a need for multi-component responses that address structural and systemic barriers to pain management, including improving access to opioid medications.

Gender and Context Matter: Behavioral and Structural Interventions for People Who Use Alcohol and Other Drugs in Africa

Heavy alcohol consumption and other drug use are prominent across Africa and increase the risk of exposure to violence, HIV acquisition, and other life-threatening injuries. This review synthesizes evidence on alcohol and other drug (AOD) interventions in Africa; evaluates the differences between interventions that do and do not specifically target populations that use AODs; and highlights the impact of comprehensive vs. brief interventions and those that address syndemic issues from a gender and contextualized lens. Literature searches were conducted to identify research outcomes of randomized interventions published between January 2010 and May 2022 that address AOD use in Africa. Thirty-five full-text articles were included in this review. Most of the identified research studies were concentrated in a few countries. Most studies were conducted in South Africa. Many of the studies comprised brief interventions. However, the most comprehensive interventions were the most effective for AOD outcomes. Several studies indicated the importance of addressing AOD use alongside gender-based violence, mental health needs, gender roles, and other social determinants that affect health outcomes. Intervening on AOD use and addressing social determinants from a gender and contextually relevant perspective is essential to ensuring the long-term health and well-being of people in Africa.

Mandrax use, sexual risk, and opportunities for pre-exposure prophylaxis among out-of-school adolescent girls and young women in Cape Town, South Africa

BACKGROUND

In South Africa (SA), adolescent girls and young women (AGYW) aged 15 - 24 years account for nearly 25% of all new HIV infections in the country. The intersection of substance use and sexual risk continues to drive the HIV epidemic among AGYW. For example, methaqualone, also known as Mandrax, has sedative effects that may affect women's ability to negotiate condom use during sex, refuse sex without a condom, or consent to sex, thereby increasing their risk for HIV. Consequently, it is critical to understand how Mandrax use affects HIV risk among AGYW and to assess awareness of and willingness to use biomedical HIV prevention methods, such as pre-exposure prophylaxis (PrEP), among AGYW who use Mandrax.

OBJECTIVES

To examine the role of Mandrax use in sexual behaviours and investigate the extent to which AGYW who use Mandrax are aware of and willing to initiate PrEP.

METHODS

Data for this report were derived from baseline and 6-month follow-up data provided by 500 AGYW participating in a cluster-randomised trial assessing the efficacy of a young woman-focused intervention to reduce substance use and HIV risk. AGYW who self-identified as black African or coloured, reported using substances, reported condomless sex in the past 3 months, and had discontinued school early were recruited from 24 community clusters across Cape Town, SA. Following consent/assent, participants provided biological specimens to test for recent drug use (including Mandrax) and completed the self-report questionnaire.

RESULTS

Logistic regression analysis revealed that the AGYW who had a positive test result for Mandrax use were less likely to use a condom with their main partner (p=0.01), and almost three times more likely to use alcohol and/or other drugs before or during their last act of sexual intercourse (p<0.001), compared with the AGYW who had a negative Mandrax test result. Mandrax use was not significantly related to PrEP awareness (p>0.10) or willingness to use PrEP (p>0.10), but 70% of AGYW who used Mandrax were willing to initiate PrEP.

CONCLUSION

The study findings highlight how Mandrax use may contribute to HIV risk among SA AGYW. Key decision-makers should consider incorporating substance use prevention efforts into existing HIV reduction programmes and equip youth-friendly clinics with the resources to identify AGYW who use Mandrax and offer them PrEP.

Substance use referral, treatment utilization, and patient costs associated with problematic substance use in people living with HIV in Cape Town, South Africa

Introduction

Despite efforts to detect and treat problematic substance use (SU) among people living with HIV (PLWH) in South Africa, integration of HIV and SU services is limited. We sought to understand whether PLWH and problematic SU were: (a) routinely referred to SU treatment, a co-located Matrix clinic, (b) used SU treatment services when referred, and (c) the individual amount spent on SU.

Methods

Guided by the RE-AIM implementation science framework, we examined patient-level quantitative screening and baseline data from a pilot clinical trial for medication adherence and problematic SU. Qualitative data came from semi-structured interviews with HIV care providers (N = 8), supplemented by patient interviews (N = 15).

Results

None of the screened patient participants (N = 121) who were seeking HIV care and had problematic SU were engaged in SU treatment, despite the freely available co-located SU treatment program. Only 1.5% of the enrolled patient study sample (N = 66) reported lifetime referral to SU treatment. On average, patients with untreated SU spent 33.3% (SD=34.5%) of their monthly household income on substances. HIV care providers reported a lack of clarity about the SU referral process and a lack of direct communication with patients about patients' needs or interest in receiving an SU referral.

Discussion

SU treatment referrals and uptake were rare among PLWH reporting problematic SU, despite the high proportion of individual resources allocated to substances and the co-located Matrix site. A standardized referral policy between the HIV and Matrix sites may improve communication and uptake of SU referrals.

Factors associated with patient-reported experiences and outcomes of substance use disorder treatment in Cape Town, South Africa

Background

Interventions are needed to improve the quality of South Africa’s substance use disorder (SUD) treatment system. This study aimed to identify factors associated with patient-reported suboptimal access, quality, and outcomes of SUD treatment to guide the design of targeted quality improvement initiatives.

Method

We analysed clinical record and patient survey data routinely collected by SUD services in the Western Cape Province, South Africa. The sample included 1097 treatment episodes, representing 32% of all episodes in 2019. Using multivariate logistic regression, we modelled socio-demographic, substance use and treatment correlates of patient-reported suboptimal access to, quality and outcomes of SUD treatment.

Results

Overall, 37.9% of patients reported substantial difficulties in accessing treatment, 28.8% reported suboptimal quality treatment, and 31.1% reported suboptimal SUD outcomes. The odds of reporting poor access were elevated for patients identifying as Black/African, in residential treatment, with comorbid mental health problems, and longer histories of substance use. Length of substance use, comorbid mental health problems, and prior SUD treatment were associated with greater likelihood of reporting suboptimal quality treatment. Patients with comorbid mental health problems, polysubstance use, who did not complete treatment, and who perceived treatment to be of poor quality were more likely to report suboptimal outcomes.

Conclusion

This study is among the first to use patient-reported experiences and outcome measures to identify targets for SUD treatment improvement. Findings suggest substantial room to improve South African SUD treatment services, with targeted efforts needed to reduce disparities in outcomes for patients of Black/African descent, for those with comorbid mental health problems, and for patients who have chronic substance use difficulties. Interventions to enhance the relevance, appropriateness, and acceptability of SUD services for these patient sub-groups are needed to improve system performance.

Using a Syndemics Framework to Understand How Substance Use Contributes to Morbidity and Mortality among People Living with HIV in Africa: A Call to Action

Substance use is increasing throughout Africa, with the prevalence of alcohol, tobacco, cannabis, and other substance use varying regionally. Concurrently, sub-Saharan Africa bears the world's largest HIV burden, with 71% of people living with HIV (PWH) living in Africa. Problematic alcohol, tobacco, and other substance use among PWH is associated with multiple vulnerabilities comprising complex behavioral, physiological, and psychological pathways that include high-risk behaviors (e.g., sexual risk-taking), HIV disease progression, and mental health problems, all of which contribute to nonadherence to antiretroviral therapy. Physiologically, severe substance use disorders are associated with increased levels of biological markers of inflammation; these, in turn, are linked to increased mortality among PWH. The biological mechanisms that underlie the increased risk of substance use among PWH remain unclear. Moreover, the biobehavioral mechanisms by which substance use contributes to adverse health outcomes are understudied in low- and middle-income countries (LMIC). Syndemic approaches to understanding the co-occurrence of substance use and HIV have largely been limited to high-income countries. We propose a syndemic coupling conceptual model to disentangle substance use from vulnerabilities to elucidate underlying disease risk for PWH. This interventionist perspective enables assessment of biobehavioral mechanisms and identifies malleable targets of intervention.

The Association of Recurrent and Multiple Types of Abuse with Adverse Mental Health, Substance Use, and Sexual Health Outcomes among Out-of-School Adolescent Girls and Young Women in Cape Town, South Africa

Although physical and sexual abuse exposure is a well-established risk for poor health, the dimensions of abuse associated with health among socially vulnerable adolescent girls and young women (AGYW) remain underexamined. This article describes associations between combinations of abuse type and timing with mental health, substance use, and sexual risk outcomes among a sample of 499 AGYW (aged 16 to 19) who had left school early and were recruited for a cluster randomized trial in Cape Town, South Africa. Approximately one-third (33.5%; 95% CI: 28.7, 38.6) of participants reported lifetime abuse. Exposure to more than one type of abuse was associated with increased risk of depression (β = 3.92; 95% CI: 2.25, 5.59) and anxiety (β = 3.70; 95% CI: 2.11, 5.28), and greater odds of polydrug use (OR = 2.10; 95% CI: 1.02, 4.34) and substance-impaired sex (OR = 2.17; 95% CI: 1.31, 3.86). Exposure to multiple types of abuse during childhood/early adolescence and again in late adolescence was associated with increased risk of depression (β = 4.65; 95% CI: 3.15, 6.14), anxiety (β = 4.35; 95% CI: 2.70, 6.02), and polydrug use (OR = 2.37; 95% CI: 1.03, 5.73). Findings underscore the need for trauma-informed interventions that reduce mental health, substance use, and sexual risks among AGYW who have experienced multiple forms of abuse and recurrent abuse.

Sustainability of a gender-focused HIV and alcohol risk-reduction intervention in usual care settings in South Africa: a mixed methods analysis

Intervention sustainability is a critical yet understudied aspect of implementation science research. To address this gap, we examined the sustainability of the Women's Health CoOp (WHC), a gender-focused, evidence-based, HIV and alcohol risk-reduction intervention, after an implementation trial. We used a mixed methods design consisting of questionnaires (n = 12), 3 focus groups (n = 11), and a semistructured interview conducted with interventionists implementing the WHC in clinics and substance use treatment programs in Cape Town, South Africa. Five out of 8 facilities implemented the WHC beyond the 6-month implementation period, and 4 were still implementing the WHC as of October 2019. Sustainability ranged from approximately 8 months to more than 3 years. At the most recent assessment, interventionists delivered the intervention to 0-20 participants in the past month. Qualitative findings indicate that long-term sustainability would require support from upper management, staff dedicated to the WHC, and booster trainings. The WHC was sustained postimplementation. Integrating the program into usual care would be feasible; however, human resources, financial, and institutional support would be needed for sustainability. To move implementation science forward, it is essential to determine sustainability beyond the presence and involvement of researchers.

Current Interventions for People Living with HIV Who Use Alcohol: Why Gender Matters

PURPOSE OF REVIEW

Alcohol is the most misused substance in the world. For people living with HIV (PLWH), alcohol misuse may impact ART adherence and viral suppression. This review of the most recently published alcohol intervention studies with PLWH examines how these studies considered gender in the samples, design, and analyses.

RECENT FINDINGS

Three searches were conducted initially, and 13 intervention studies fit our criteria with alcohol outcomes. In general, most studies did not consider gender and had used small samples, and few demonstrated significant efficacy/effectiveness outcomes. Five studies considered gender in their samples or analyses and/or were woman-focused with larger samples and demonstrated significant outcomes. It is essential for women who misuse alcohol to not only be well represented in alcohol and HIV research but also for studies to consider the barriers to reaching them and their contextual demands and/or co-occurring issues that may affect participation and outcomes in intervention research.

In search of 'community': a critical review of community mental health services for women in African settings

Community is deemed a central resource for the improvement of health, across disciplines, contexts and conditions. However, what is meant by this term is rarely critically explored. In Global Mental Health, considerable efforts in recent years have been directed towards scaling up 'community' approaches, with variable success, creating the need to better understand approaches to its use. Our study contributes to this need, through a critical review of studies engaging with the term 'community' in relation to women's mental health services in African settings. Our review explored 30 peer-reviewed articles from the past 15 years, which were systematically evaluated for quality of evidence. Studies were then analysed using a blend of conventional and directed content analysis to unpack perspectives on the term's use in intervention and phenomenological studies. We identified four broad categories of community: (1) place (shared geographical location or institutional affiliation), (2) practice (belongingness to a shared activity or profession), (3) symbols (meanings and experiences associated with shared community life) and (4) identity (diagnostic identity around a mental health condition). Analysis identified community of place as the most common primary focus of interest across the sample, with 80% of papers referencing this dimension. We noted that in studies where communities of practice were the focus, this was in relation to leveraging local knowledge to inform or support service delivery of intervention programmes, often designed by outsiders. Implications for future policy and mental health services research are discussed.

The intersection of gender and drug use-related stigma: A mixed methods systematic review and synthesis of the literature

BACKGROUND

Substance use-related stigma is a significant barrier to care among persons who use drugs (PWUD). Less is known regarding how intersectional identities, like gender, shape experiences of substance use-related stigma. We sought to answer the following question: Do men or women PWUD experience more drug use stigma?

METHODS

Data were drawn from a systematic review of the global, peer-reviewed scientific literature on substance use-related stigma conducted through 2017 and guided by the Stigma and Substance Use Process Model and PRISMA guidelines. Articles were included in the present analysis if they either qualitatively illustrated themes related to the gendered nature of drug use-related stigma, or quantitatively tested the moderating effect of gender on drug use-related stigma.

RESULTS

Of the 75 studies included, 40 (53 %) were quantitative and 35 (47 %) were qualitative. Of the quantitative articles, 22 (55 %) found no association between gender and drug use-related stigma, 4 (10 %) identified women who use drugs (WWUD) were more stigmatized, and 2 (5 %) determined men who use drugs (MWUD) were more stigmatized. In contrast, nearly all (34; 97 %) of the qualitative articles demonstrated WWUD experienced greater levels of drug use-related stigma.

CONCLUSION

The quantitative literature is equivocal regarding the influence of gender on drug use-related stigma, but the qualitative literature more clearly demonstrates WWUD experience greater levels of stigma. The use of validated drug use-related stigma measures and the tailoring of stigma scales to WWUD are needed to understand the role of stigma in heightening the disproportionate harms experienced by WWUD.

The role of reward and reinforcement in understanding alcohol use among adults living with HIV in South Africa

OBJECTIVE

Most research investigating reinforcement in alcohol use is from high-income countries. The current study sought to understand the association of different reinforcement types (alcohol-specific reward, environmental reward, behavioral activation) with multiple measures of alcohol use and cravings among individuals living with HIV in South Africa.

METHOD

Baseline data were obtained from a substance use clinical trial in Cape Town (N = 65). Unhealthy alcohol use was measured using the biomarker phosphatidylethanol (PEth), Alcohol Use Identification Test (AUDIT-C), average number of drinks from the timeline follow back (TLFB), and self-reported cravings. Reinforcement was measured using the proportion of income spent on alcohol (alcohol-specific reward), both subscales of the Reward Probability Index (environmental reward), and the Behavioral Activation Depression Scale (activation). Poisson and linear regression analyses were conducted.

RESULTS

Each percentage point increase in income spent on alcohol was significantly associated with PEth, RR = 1.004 [95% CI (1.001, 1.007)], which translates to a 13.6% increase in the relative risk of unhealthy alcohol use for the average person in the study. More alcohol-specific reward was significantly associated with higher scores on the AUDIT-C, higher average number of drinks on the TLFB, and more cravings. Higher activation was associated with lower scores on the AUDIT-C. Neither subscale of environmental reward was associated with model outcomes.

CONCLUSION

Greater alcohol-specific reward and less behavioral activation were associated with more frequent and unhealthy alcohol use in this setting, but not environmental reward. Findings highlight how different reinforcement types potentially influence alcohol use in a low-resource global setting. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Mothers experiences of the Parenting Under Pressure Program (PuP) in a Residential Therapeutic Community: A qualitative study

Several studies suggest parental substance use, while not always the case, exposes children to a higher risk of physical, psychological, behavioral and emotional problems. Identifying interventions that best support the parent and child needs is imperative. The PuP programme aims to improve family functioning and child outcomes by supporting parents who are or have been drug or alcohol dependent. PuP combines psychological principles relating to parenting, child behavior and parental emotion regulation within a case-management model. The current study was the first evaluation of the PuP program in a residential setting globally. Twenty-three women took part in pre and post-program qualitative interviews. Guilt was a dominant theme across interviews. The principal expectation of participants was to improve their relationships and access to their children. The benefits of the PuP program to the women and their children, as reported by participants, were immediate and direct. As the women progressed through the program, they were visibly building belief in their abilities to parent.

Women and barriers to harm reduction services: a literature review and initial findings from a qualitative study in Barcelona, Spain

Background

There are an estimated 3.2 million women who inject drugs worldwide, constituting 20% of all people who inject drugs. The limited data that are available suggest that women who inject drugs are at greater risk of HIV and viral hepatitis acquisition than men who inject drugs. This increased vulnerability is a product of a range of environmental, social and individual factors affecting women, which also affect their ability to engage in health promoting services such as harm reduction.

Methods

The researchers undertook a narrative literature review examining access to harm reduction services for women who use drugs in Europe and conducted semi-structured focus groups with women who use drugs and harm reduction and prison health workers in Barcelona, Spain.

Results

Women who use drugs face multiple barriers to accessing harm reduction services. These include stigma, both in society in general and from health and harm reduction workers in prisons and in the community; gender-based violence and a lack of services that are equipped to address the interaction between drug use and experiences of violence; criminalisation in the form of legal barriers to access, arrest and harassment from law enforcement, and incarceration; and a lack of services focused on the specific needs of women, notably sexual and reproductive health services and childcare. In Barcelona, participants reported experiencing all these barriers, and that their engagement with the Metzineres harm reduction centre had to some extent mitigated them. However, women continued to experience structural barriers to harm reduction service access.

Conclusions

Women and gender non-conforming people who use drugs face unique barriers to accessing harm reduction services. While services such as Metzineres can be life changing and life affirming for its members, it is incumbent on states to act to address the structural barriers to health faced by women who use drugs.

Implementation science outcomes of a gender-focused HIV and alcohol risk-reduction intervention in usual-care settings in South Africa

BACKGROUND

South Africa has the highest HIV prevalence globally, which disproportionately affects women. Hazardous alcohol use reduces antiretroviral adherence which can lead to adverse health. Few evidence-based interventions addressing hazardous alcohol use and HIV have been implemented in real-world settings. This study aimed to evaluate implementation outcomes from the Women's Health CoOp (WHC)-an evidence-based gender-focused HIV intervention-which was implemented in Cape Town.

METHODS

We conducted this implementation science trial using a modified stepped-wedge design. Four health clinics were paired with four substance use rehabilitation programs and randomized into four cycles. Women living with HIV and who use alcohol or other drugs were recruited into each cycle (n = 120 each cycle). We assessed adoption, acceptability, appropriateness, cost, and fidelity using a mixed methods approach.

RESULTS

Adoption: 100 % of staff trained in the WHC and designated as interventionists delivered one or more workshops. Acceptability: Interventionists found the WHC content beneficial to their patients and the WHC improved connections between clinical units in facilities. Appropriateness: The WHC aligned with facility goals to improve antiretroviral adherence and reduce alcohol use; however, there were implementation challenges, including staff shortages, stigma, and few places to refer women for supportive services. Cost: The cost of implementing the WHC was 20.59 ZAR (1.40 USD) per attendee. Fidelity: Interventionists implemented the WHC with high fidelity and quality.

CONCLUSIONS

The findings suggest it is feasible to integrate the WHC into usual-care settings. Future efforts to scale up the intervention will need to address social and structural implementation challenges.

TRIAL REGISTRATION

NCT02733003 approved 1/21/2016.

The PrEPARE Pretoria Project: protocol for a cluster-randomized factorial-design trial to prevent HIV with PrEP among adolescent girls and young women in Tshwane, South Africa

BACKGROUND

Despite increased prevention efforts, HIV remains the leading cause of death among adolescent girls and young women in South Africa. Although research indicates important determinants of HIV acquisition at the individual and interpersonal levels, structural-level stigma and discrimination continue to be critical barriers to reaching and retaining this key population for HIV prevention and sexual and reproductive health services. Innovative and multilevel interventions are needed that can address the intersectional structural and gender issues that young women face, including stigma, alcohol and drug use, gender-based violence, and other risk factors when seeking health services. Oral pre-exposure prophylaxis (PrEP) taken daily has been found to be an effective biomedical HIV prevention tool. Testing a comprehensive gender-focused biobehavioral HIV prevention intervention that is inclusive of social ecological determinants, such as stigma and discrimination reduction in clinics, is critical for reducing HIV among adolescent girls and young women.

METHODS

This project involves both a Community Collaborative Board and a Youth Advisory Board in helping to adapt the Young Women's Health CoOp intervention and the Health Policy Project (HPP) Stigma and Discrimination (S&D) reduction training curriculum to the setting and population. This study uses a two-by-two factorial design with stratified randomization of 12 clinics, each with distinct catchment areas. The Young Women's Health CoOp addresses substance use, sexual risk, violence prevention and sexual negotiation, condom demonstration, and problem solving with the following additions: knowledge of PrEP, the importance of PrEP adherence, and sexual and reproductive health. Adolescent girls and young women will be assessed with behavioral and biological measures at baseline, 3-, 6- and 9-month follow-up. The S&D reduction training is provided for all staff in the clinics randomized to this condition. Clinic staff will be surveyed at baseline, 4- and 8-month follow-up. We will recruit 900 AGYW from communities in the 12 clinic catchment areas.

DISCUSSION

The study findings, if efficacious across the outcomes, will be incorporated into the gender-focused HIV prevention intervention toolkit and disseminated to inform multilevel prevention approaches.

TRIAL REGISTRATION

ClinicalTrials.gov. Identifier: NCT04048551 (Recruiting). Registered: August 7, 2019 (Retrospectively registered).

Preventing transitions into injection drug use: A call for gender-responsive upstream prevention

In 2017, there were large increases (260-500%) in overdose deaths among women in the United States across age groups (30-64 years and 55-64 years). In addition, U.S. women who inject drugs (WWID) are at increased risk for substance use-related disease transmission, bacterial infections, as well as sexual and physical violence compared to men who inject drugs. Relatedly, women face unique access barriers to substance use-related services, such as stigma and low coverage of gender-specific drug use-related services. Despite these heightened risks experienced by WWID, interventions specifically tailored to preventing women from transitioning into injection drug use have not been developed to date. As such, we advocate for the development of gender-responsive programs to prevent injection drug use initiation. This is critical to ensuring a comprehensive approach to preventing injection drug use initiation among those populations at highest risk of injection-related morbidity and mortality.

Acceptability and feasibility of a brief substance use intervention for adolescents in Cape Town, South Africa: A pilot study

Substance use is prevalent among South African adolescents, but few interventions exist to reduce risk of harm. This study assesses the feasibility, acceptability and preliminary effects of a brief intervention for reducing adolescent substance use and other risk behaviours. This single-arm feasibility test recruited 30 substance-using adolescents and their primary caregiver. Participants received separate interventions (2 sessions for adolescents, 1 session for caregivers), with a subsample randomly selected for post-intervention interviews. Feasibility was measured by the proportion of eligible adolescents who were enrolled and retained in the study. Interviews explored acceptability, and changes in outcomes from baseline to 1-month follow-up assessed preliminary effects of the intervention. Thirty of 43 (69.8%) eligible adolescents and their caregivers were enrolled, with 29 adolescents (96.7%) and 28 caregivers (93.3%) completing the intervention. Twenty-eight adolescents (93.3%) and 29 caregivers (96.7%) were retained at follow-up. Frequency of alcohol, cannabis use and delinquent-type behaviours decreased significantly from baseline to follow-up. Participants appreciated the intervention content and delivery and felt that it facilitated behaviour change. Suggestions for improving the intervention were provided. This study found that the intervention is feasible, acceptable and had promising effects on adolescent behaviour. Efficacy must be established with a randomised controlled trial.

Young South African Women on Antiretroviral Therapy Perceptions of a Psychological Counselling Program to Reduce Heavy Drinking and Depression

Young women in South Africa remain most at risk for HIV infection. Several factors contribute to the high incidence rate in this population, including hazardous drinking and depression. Addressing common mental disorders (CMDs) such as depression and alcohol use disorders is key to effective HIV treatment. We explored the experiences and perceptions of young South African women on antiretroviral therapy (ART) of a lay health worker (LHW)-delivered psychosocial intervention based on motivational interviewing (MI) and problem-solving therapy (PST) to reduce heavy drinking and depression. We conducted 27 in-depth interviews with young women (aged 18-35) recruited from 16 primary care clinics in the Western Cape province of South Africa. Discussion topics included young women's life experiences leading to their enrollment in the program, their perceptions of the counselling sessions and the quality of their interaction with the counsellor. Qualitative data were analyzed using a framework approach. The findings highlighted the impact adverse life experiences and stressful life circumstances have on young women's use of alcohol and symptoms of depression and the effect this has on ART adherence. The findings suggest that women found the intervention components that helped them develop strategies for coping with their past experiences, managing current life stressors, and regulating negative thoughts and emotions most beneficial. Taken together, these findings confirm the acceptability of LHW-delivered MI-PST counselling for this population, but suggest that the relevance of the MI-PST intervention for this highly vulnerable population could be further enhanced by including a focus on psychological trauma.

"Too much boredom isn't a good thing": Adapting behavioral activation for substance use in a resource-limited South African HIV care setting

South Africa has the largest HIV/AIDS burden globally. In South Africa, substance use is prevalent and interferes with HIV treatment adherence and viral suppression, and yet it is not routinely treated in HIV care. More research is needed to adapt scalable, evidence-based therapies for substance use for integration into HIV care in South Africa. Behavioral activation (BA), originally developed as an efficacious therapy for depression, has been feasibly used to treat depression in low- and middle-income countries and substance use in high-income settings. Yet, to date, there is limited research on using BA for substance use in low- and middle-income countries. Guided by the ADAPT-ITT framework, this study sought to adapt BA therapy for substance use in HIV care in South Africa. We conducted semistructured individual interviews among patients (n = 19) with moderate/severe substance use and detectable viral load, and HIV care providers and substance use treatment therapists (n = 11) across roles and disciplines at 2 clinic sites in a peri-urban area of Cape Town. We assessed patient and provider/therapist views on the appropriateness of the BA therapy model and sought feedback on isiXhosa-translated BA therapy components. Participants identified the central role of boredom in contributing to substance use and saw the BA therapy model as highly appropriate. Participants identified church and religious practices, sports, and yard/housework as relevant substance-free activities. These findings will inform adaptations to BA therapy for substance use and HIV medication adherence in this setting. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Nurse-Delivered Cognitive Behavioral Therapy for Adherence and Depression Among People Living With HIV (the Ziphamandla Study): Protocol for a Randomized Controlled Trial

BACKGROUND

There is an unmet need to develop effective, feasible, and scalable interventions for poor adherence and depression in persons living with HIV in low- and middle-income countries (LMIC).

OBJECTIVE

This study aims to investigate the effectiveness of a nurse-delivered cognitive behavioral therapy (CBT) intervention for adherence and depression (CBT-AD) among persons living with HIV who are failing first-line antiretroviral therapy (ART) in Cape Town, South Africa.

METHODS

This study is a 2-arm randomized controlled trial of CBT-AD integrated into the HIV primary care setting in South Africa. A total of 160 participants who did not achieve viral suppression from their first-line ART and have a unipolar depressive mood disorder will be randomized to receive either 8 sessions of CBT-AD or enhanced treatment as usual. Participants will be assessed for major depressive disorder using the Mini International Neuropsychiatric Interview at baseline and 4, 8, and 12 months. The primary outcomes are depression on the Hamilton Depression Scale (HAM-D; as assessed by a blinded assessor) at the 4-month assessment and changes in ART adherence (assessed via real-time, electronic monitoring with Wisepill) between baseline and the 4-month assessment. Secondary outcomes are HIV viral load and CD4 cell count at the 12-month assessment as well as ART adherence (Wisepill) and depression (HAM-D) over follow-up (4-, 8-, and 12-month assessments).

RESULTS

The trial commenced in August 2015 and recruitment began in July 2016. Enrollment was completed in June 2019.

CONCLUSIONS

Results of this study will inform whether an existing intervention (CBT-AD) can be effectively administered in LMIC by nurses with training and ongoing supervision. This will present unique opportunities to further explore the scale-up of a behavioral intervention to enhance ART adherence among persons living with HIV with major depression in a high-prevalence setting, to move toward achieving The Joint United Nations Programme on HIV/AIDS 90-90-90 goals.

TRIAL REGISTRATION

ClincialTrials.gov NCT02696824; https://clinicaltrials.gov/ct2/show/NCT02696824.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/14200.

Training the Addiction Treatment Workforce in HIV Endemic Regions: An Overview of the South Africa HIV Addiction Technology Transfer Center Initiative

The South Africa HIV Addiction Technology Transfer Center (ATTC) was formed in 2017 to train health professionals and nonprofessional lay workers in evidence-based addiction interventions as a strategy for addressing the country's HIV epidemic. This article describes the Year 1 activities of the South Africa HIV ATTC including an initial needs assessment with high-level stakeholders, an advisory board meeting with South African government and nongovernment agencies, a learning exchange with other international ATTCs, and the identification of Screening, Brief Intervention, and Referral to Treatment (SBIRT) as a focal intervention for widespread training. The article details the culmination of Year 1 activities via a national forum on SBIRT and presents posttraining satisfaction data across SBIRT events. Lessons learned during the first year include the importance of building strong partnerships with high-level stakeholders, conducting a targeted needs assessment, and identifying a focal intervention for widespread dissemination. Trainees reported high satisfaction and intention to use the knowledge and skills gained. Overall, the methods used by the South Africa HIV ATTC demonstrate a novel approach to training health professionals and lay health workers in evidence-based addiction services as a means of improving HIV outcomes.

Service providers' perceptions of barriers to the implementation of trauma-focused substance use services for women in Cape Town, South Africa

BACKGROUND

A substantial number of South African women with substance use disorders also report psychological trauma related to experiences of physical and sexual abuse. Trauma-focused substance use programmes may support recovery from co-occurring substance use disorders and psychological trauma, yet integrated programmes are not widely available in South Africa. As part of the process of developing a trauma-focused substance use programme for South African women, we explored service providers' views of the feasibility of implementing trauma-focused substance use interventions within usual care settings in Cape Town, including potential barriers that need to be considered when planning for implementation.

METHODS

We conducted 16 in-depth interviews with key informants responsible for planning or delivering substance use, psychological trauma or gender-based violence services to women in Cape Town. Guided by Extended Normalisation Process Theory, interviews explored participants' perceptions of the potential value of trauma-focused substance use programmes, the feasibility of their implementation, and factors that may facilitate or hinder the implementation of trauma-focused substance use programmes. Qualitative data were analysed using the framework approach.

RESULTS

Three themes emerged: (1) Potential for the implementation of trauma-focused substance use programmes, describing participants' views of the acceptability of these programmes; (2) Capacity for intersectoral collaboration, which participants considered necessary for limiting barriers to implementation; and (3) Co-operation with community structures to enhance capability for implementation.

CONCLUSION

Findings show potential for implementing trauma-focused substance use interventions in South Africa, however context-specific capacity and capability barriers need to be considered and addressed for implementation to be successful.

Women and substance use disorders in low- and middle-income countries: A call for advancing research equity in prevention and treatment

Although the prevalence of substance use disorders (SUDs) is higher among men, women with SUDs in low- and middle-income countries (LMICs) face unique challenges. Poverty and adversity, inequality of women, and disparities in access to treatment and prevention services exacerbate biological, psychological and social correlates of substance use disorders for women living in low-resource settings. Increasing the inclusion of women in research has long been a goal, though even high income countries struggle to achieve parity. In LMICs, women with SUDs are often neglected from global research due to underreporting and the disproportionate focus of global substance use research on men. We will discuss risk factors for SUDs that are particularly relevant for women residing in LMICs in order to gain insight into neglected areas of research and opportunities for prevention and treatment.

The adaptation of an evidence-based brief intervention for substance-using adolescents and their caregivers

Objective: Adolescent substance use is prevalent and associated with additional risk behaviours. Research shows that evidence-based brief interventions with adolescents and their main caregiver may mitigate the progression of substance use. Method: We used the ADAPT-ITT framework to develop a needs-based, culturally-sensitive intervention. Five focus groups with adolescents (n = 30), three focus groups with separate main caregivers of adolescents who use substances (n = 21), key informant interviews and an expert meeting, were conducted. Results: Adolescents described the need to decrease risk behaviours, while adolescents and caregivers requested additional support. The core components of the original intervention were retained, with some additions. The newly adapted RAD-PAL intervention was viewed as acceptable. Conclusion: Despite apparent acceptability, we need to test feasibility and efficacy in a trial.

Prevalence and correlates of depression and anxiety symptoms among out-of-school adolescent girls and young women in Tanzania: A cross-sectional study

BACKGROUND

In sub-Saharan Africa, adolescent girls and young women (AGYW) who are out of school are at higher risk of depressive and anxiety disorders compared to their school attending peers. However, little is known about the prevalence and risk factors for these conditions among out-of-school AGYW. This study examines the prevalence of depression and anxiety and associated factors in a community sample of out-of-school AGYW in Tanzania.

METHODS

A cross-sectional analysis of baseline data from an on-going cluster randomized controlled trial in North-West Tanzania was conducted. A total of 3013 out-of-school AGYW aged 15 to 23 years from 30 clusters were included. Anxiety and depression were assessed using the Patient Health Questionnaire (PHQ-4), a tool comprising of PHQ-2 and Generalized Anxiety Disorders (GAD-2) screeners. Data were collected using Audio Computer-Assisted Self-Interview (ACASI). A random-effects logistic regression was fitted for binary outcomes and an ordinal logistic regression model with robust variance was used to adjust for clustering at the village level. Logistic regression and ordinal logistic regression were used to explore the associations between mental disorders symptoms and other factors.

RESULTS

The prevalence of depressive (PHQ-2 ≥ 3) and anxiety (GAD-2 ≥ 3) symptoms among out-of-school AGYW were 36% (95% CI 33.8%-37.3%) and 31% (95% CI 29.0%-32.3%) respectively. Further, using the PHQ-4 tool, 33% (95% CI 30.8%-34.2%) had mild, 20% (95% CI 18.3%-21.1%) moderate and 6% (95% CI 5.5%-7.2%) had severe symptoms of anxiety and depression. After adjusting for other covariates, two factors most strongly associated with having anxiety symptoms were violence experience from sexual partners (AOR = 1.63, 95% CI: 1.36-1.96) and HIV positive status (AOR = 1.54, 95% CI: 1.03-2.31). Likewise, living alone, with younger siblings or others (AOR = 2.51, 95% CI: 1.47-4.29) and violence experience from sexual partners (AOR = 1.90, 95% CI: 1.59-2.27) were strongly associated with depression symptoms. Having savings (AOR = 0.81, 95% CI: 0.70-0.95) and emotional support (AOR = 0.82, 95% CI: 0.67-0.99) were protective against depression and anxiety, respectively.

CONCLUSION

Depressive and anxiety symptoms are prevalent among out-of-school AGYW in Tanzania. The findings emphasize the need to strengthen preventive interventions and scale-up mental health disorder screening, referral for diagnosis and management.

"Someone who is in this thing that I am suffering from": The role of peers and other facilitators for task sharing substance use treatment in South African HIV care

South Africa is home to the largest number of people living with HIV/AIDS in the world. Alongside the HIV/AIDS epidemic, problematic alcohol and other drug (AOD) use is prevalent and associated with poor HIV treatment and secondary HIV prevention outcomes. International guidelines and local policy both support the integration of mental health care and AOD treatment into HIV care, yet barriers exist to implementation. This study aimed to explore patient and provider perspectives on the integration of HIV and AOD treatment services in Cape Town, South Africa. This included barriers and facilitators to task sharing AOD treatment in HIV care and preferences for a task shared approach to integrating AOD treatment in HIV care, including who should deliver the behavioural intervention. We conducted thirty semi-structured qualitative interviews with HIV and AOD treatment staff, providers, and people living with HIV/AIDS (PLWH) with moderate, problematic AOD use and difficulties (personal or structural) adhering to HIV treatment. Findings illustrated several key themes: (1) the separation between AOD and HIV services (a "siloed treatment experience"), even in the context of geographic co-location; (2) low AOD treatment literacy among HIV patients and providers, including a low awareness of existing AOD use services, even when co-located; (3) substance use stigma as a barrier to HIV and AOD treatment integration; (4) a strong patient preference for peer interventionists; and (5) the role of community health workers (CHWs) in detecting AOD use among some PLWH who had not followed up in HIV care. These findings will inform a future type 1 hybrid effectiveness-implementation trial, guided by the RE-AIM framework, to evaluate a task shared, evidence-based intervention to address problematic AOD use and improve HIV medication adherence in this setting.

Assessing capability for implementing mental health counselling within primary care facilities in a middle-income country: A feasibility study

WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: Integrating mental health counselling into primary care services is a recommended strategy for reducing the mental health treatment gap in low- and middle-income countries. To support this strategy, potential barriers to counselling integration must be identified and addressed. Organizational preparedness for implementation may influence the extent to which the introduction of counselling is successful. Features of primary care facilities associated with preparedness for the implementation of mental health counselling have not been explored. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: This study uses a novel approach to explore variations in preparedness of primary care services to implement counselling and factors potentially associated with these variations. Findings suggest there is considerable variation in the preparedness of facilities to implement counselling. Organizational factors such as resource availability, management style and facility environment are potentially associated with capability for implementing mental health counselling. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Health planners could use this method to identify poorly functioning services that may benefit from additional interventions to build preparedness for counselling implementation. Future research should examine whether differences in facility preparedness impact on the implementation and outcomes of this service. Abstract Introduction Differences in primary care facilities' preparedness for implementing mental health counselling may affect the implementation process but have rarely been studied. Aim To assess the feasibility of using a novel methodological approach to explore variations in capability for implementing mental health counselling and factors potentially associated with this variation among primary care services in the Western Cape, South Africa. Methods Staff from 26 facilities participated in discussions about their facility's mental health implementation capability. Three researchers conducted observations of the facility's environment, staff-patient interactions and resources. We used qualitative comparative analysis to identify factors potentially associated with implementation capability. Results Facilities appeared to vary in their capability for implementing counselling services. The availability of person-centred health services, a therapeutic environment and sufficient human resources may be requirements for implementation preparedness. Other factors that seem to support preparedness include the availability of confidential space for counselling and an adequately managed facility. Discussion This study identified several features of well-functioning primary care facilities. Facilities with these features may be better prepared to implement a new counselling service. Implications for practice This method may identify facilities that are poorly prepared for implementation that could benefit from preparedness-building interventions. Whether differences in preparedness affect counselling outcomes is yet to be established.

A trauma-informed substance use and sexual risk reduction intervention for young South African women: a mixed-methods feasibility study

OBJECTIVES

Sexual and physical trauma and substance use are intersecting risks for HIV among young women. This study assesses the feasibility, acceptability and preliminary effects of a novel trauma-informed substance use and sexual risk reduction intervention for young South African women.

DESIGN

A single arm feasibility test and qualitative interviews of participants.

PARTICIPANTS

Sixty women, between 18 and 25 years of age, who reported trauma exposure, substance use and recent condom-less sex were recruited. Twenty participants were randomly selected for qualitative interviews.

INTERVENTION

A six-session group-based intervention.

MAIN OUTCOME MEASURES

We examined the proportion of women who provided consent, completed counselling and were retained in the study. Qualitative interviews explored intervention acceptability. Preliminary effects of the intervention on substance use, mental health (depression, psychological distress and trauma symptoms) and sexual risk outcomes (STI symptoms, number of partners and condomless sex) were explored.

RESULTS

Of the 66 eligible women, 91% were enrolled. Intervention completion rates were low; 35% attended all sessions. On average, participants attended four sessions (M=3.8, SD=1.3). A 93% follow-up rate was achieved at the 3-month endpoint. In this single group design, reductions in the proportion of participants who tested positive for methamphetamine, cannabis and methaqualone were observed at the 3-month endpoint. Symptoms of depression, psychological distress and trauma; number of STI symptoms; and number of sexual partners also decreased. Outcomes were similar for participants who completed up to four and those who completed five or more sessions. Participants thought the intervention was highly beneficial and proposed modifications to enhance acceptability.

CONCLUSIONS

This novel intervention seems acceptable and holds potential benefits for trauma-exposed women who use substances. Truncating the intervention may enhance the likelihood of its implementation. The efficacy of the intervention for improving substance use, sexual risk and mental health outcomes requires testing in a controlled design.

Trastornos por consumo de sustancias: entre las inequidades y el estigma

Las personas que reúnen criterios para trastornos por consumo de sustancias (TCS) con frecuencia son víctimas del complejo estigma-discriminación (CED), no sólo por parte de la sociedad general, sino también por profesionales de la salud y la presencia de autoestigma. No obstante, la relación de los TCS con factores biológicos predisponentes y condiciones sociales adversas se considera que estos son ‘autoinducidos’. Asimismo, se conoce que en los TCS se presentan cambios biológicos, psicológicos o del desarrollo que menoscaban la decisión de abandono y la persistencia en el consumo, a pesar de las consecuencias negativas físicas, emocionales y sociales. El CED relacionado con el TCS es un estresor que deteriora aún más la calidad de vida de las personas consumidoras y, al mismo tiempo, se configura como una barrera de acceso a servicios de salud. Es necesario diseñar e investigar la efectividad de estrategias para reducir el CED relacionado con TCS en diferentes poblaciones y contextos.

Community health worker-delivered counselling for common mental disorders among chronic disease patients in South Africa: a feasibility study

OBJECTIVES

To examine the feasibility and acceptability of integrating a 'designated' approach to community health worker (CHW)-delivered mental health counselling (where existing CHWs deliver counselling in addition to usual duties) and a 'dedicated' approach (where additional CHWs have the sole responsibility of delivering mental health counselling) into chronic disease care.

DESIGN

A feasibility test of a designated and dedicated approach to CHW-delivered counselling and qualitative interviews of CHWs delivering the counselling.

SETTING

Four primary healthcare clinics in the Western Cape, South Africa allocated to either a designated or dedicated approach and stratified by urban/rural status.

PARTICIPANTS

Forty chronic disease patients (20 with HIV, 20 with diabetes) reporting hazardous alcohol use or depression. Interviews with seven CHWs.

INTERVENTION

Three sessions of structured mental health counselling.

MAIN OUTCOME MEASURES

We assessed feasibility by examining the proportion of patients who were willing to be screened, met inclusion criteria, provided consent, completed counselling and were retained in the study. Acceptability of these delivery approaches was assessed through qualitative interviews of CHWs.

RESULTS

Regardless of approach, a fair proportion (67%) of eligible patients were willing to receive mental health counselling. Patients who screened positive for depression were more likely to be interested in counselling than those with hazardous alcohol only. Retention in counselling (85%) and the study (90%) was good and did not differ by approach. Both dedicated and designated CHWs viewed the counselling package as highly acceptable but requested additional training and support to facilitate implementation.

CONCLUSIONS

Dedicated and designated approaches to CHW-delivered mental health counselling were matched in terms of their feasibility and acceptability. A comparative efficacy trial of these approaches is justified, with some adjustments to the training and implementation protocols to provide further support to CHWs.

A Mixed-Methods Evaluation of the Implementation of a Performance Measurement System for South Africa's Substance Use Treatment Services

OBJECTIVE

Minimal knowledge exists on the factors that affect implementation of performance measurement systems, particularly in low- and middle-income countries (LMICs). To address this, we describe the implementation of a performance measurement system for South Africa's substance abuse treatment services known as the Service Quality Measures (SQM) initiative.

METHOD

We conducted a mixed-methods evaluation of system implementation. We surveyed 81 providers about the extent of system implementation within their agencies and the factors that facilitated implementation. We conducted 26 in-depth interviews of providers' perceived barriers and facilitators to implementation.

RESULTS

The overall penetration of this system was high. Almost all providers viewed the system as feasible to implement, acceptable, appropriate for use in their context, and useful for guiding service improvements. However, the extent of implementation varied significantly across sites (p < .05). Leadership support (p < .05) was associated with increased implementation in multivariable analyses. Providers reflected that high rates of patient attrition, variability in willingness to implement the system, and limited capacity for interpreting performance feedback affected the extent of system implementation.

CONCLUSIONS

It is feasible to implement a performance measurement system in LMICs if the system is acceptable, appropriate, and useful to providers. To ensure the utility of this system for treatment service strengthening, system implementation must be optimized. Efforts to enhance target population coverage, strengthen leadership support for performance measurement, and build capacity for performance feedback utilization may enhance the implementation of this performance measurement system.

Adolescent female school dropouts who use drugs and engage in risky sex: effects of a brief pilot intervention in Cape Town, South Africa

Female adolescents from socioeconomically underserved communities in Cape Town, South Africa, who have dropped out of school, use substances, and engage in risky sex behaviour are at risk of HIV. Tailored gender-focused HIV behavioural interventions for this key population are needed to mitigate these risk factors. A pilot trial of a woman-focused risk-reduction intervention for adolescents was conducted (N = 100), with a one-month follow-up appointment. Participants in the intervention group attended two group workshops. Data were examined for significant differences within and between the groups. At baseline, 94% of participants tested positive for cannabis, 17% were HIV-positive and 11% were pregnant. Ninety-two participants returned for 1-month follow-up. At follow-up, the proportion who tested positive for cannabis use decreased significantly in both the intervention (p = 0.07) and control groups (p = 0.04). Impaired sex with any partner (p = 0.02), or with main partner (p = 0.06) decreased among the intervention group. Impaired sex with a main partner was less likely in the intervention group (p = 0.07) in the regression model. In conclusion, findings indicate a need for HIV prevention interventions among out-of-school female adolescents. Intervention acceptability was high, and there were some decreases in sexual risk behaviour among intervention participants which is promising. Future intervention research with this key population involving larger sample sizes and longer follow-up periods will help to determine intervention efficacy.

Substance abuse treatment engagement, completion and short-term outcomes in the Western Cape province, South Africa: Findings from the Service Quality Measures Initiative

BACKGROUND

Optimizing the effectiveness of substance use disorder (SUD) treatment is critical in low-and middle-income countries (LMICs) with limited opportunities for SUD treatment. This is the first study to identify targets for interventions to improve the quality of SUD treatment in a LMIC.

METHOD

We explored correlates of three indicators of treatment quality (treatment engagement, completion and abstinence at treatment exit) using data from a SUD performance measurement system implemented in the Western Cape Province of South Africa. The sample included data from 1094 adult treatment episodes representing 53% of the treatment episodes in 2016. Using multivariate logistic regression analyses, we modeled socio-demographic, substance use and program correlates of treatment engagement, completion, and abstinence at treatment exit.

RESULTS

Overall, 59% of patients completed treatment (48% of patients from outpatient services). Treatment completion was associated with greater likelihood of abstinence at treatment exit. Patients were more likely to complete treatment if they engaged in treatment, were older, and had more severe drug problems (characterized by daily drug use and heroin problems) and attended programs of shorter duration. Residential treatment was associated with greater likelihood of treatment engagement, completion, and abstinence at treatment exit.

CONCLUSION

Improving rates of outpatient treatment completion will enhance the effectiveness of South Africa's SUD treatment system. Interventions that promote engagement in treatment, particularly among younger patients; reduce program length through referral to step-down continuing care; and ensure better matching of drug problem to treatment level and type could improve rates of treatment completion.

Comparing dedicated and designated models of integrating mental health into chronic disease care: study protocol for a cluster randomized controlled trial

BACKGROUND

In low- and middle-income countries (LMIC), it is uncertain whether a "dedicated" approach to integrating mental health care (wherein a community health worker (CHW) has the sole responsibility of delivering mental health care) or a "designated" approach (wherein a CHW provides this service in addition to usual responsibilities) is most effective and cost-effective. This study aims to compare the effectiveness and cost-effectiveness of these two models of service integration relative to treatment as usual (TAU) for improving mental health and chronic disease outcomes among patients with HIV or diabetes.

METHODS/DESIGN

This is a cluster randomised trial. We will randomise 24 primary health care facilities in the Western Cape Province of South Africa to one of three study arms. Within each cluster, we will recruit 25 patients from HIV and 25 from diabetes services for a total sample of 1200 participants. Eligible patients will be aged 18 years or older, take medication for HIV or diabetes, and screen positive on the Alcohol Use Disorder Identification Test for hazardous/harmful alcohol use or depression on the Centre for Epidemiology Scale on Depression. Participants recruited in clinics assigned to the designated or dedicated approach will receive three sessions of motivational interviewing and problem-solving therapy, while those recruited at TAU-assigned clinics will be referred for further assessment. Participants will complete an interviewer-administered questionnaire at baseline, and at 6 and 12 months post-enrolment to assess change in self-reported outcomes. At these end points, we will test HIV RNA viral load for participants with HIV and HbA1c levels for participants with diabetes. Primary outcomes are reductions in self-reported hazardous/harmful alcohol use and risk of depression. Secondary outcomes are improvements in adherence to chronic disease treatment, biomarkers of chronic disease outcomes, and health-related quality of life. Mixed-effect linear regression models will model the effect of the interventions on primary and secondary outcomes. The cost-effectiveness of each approach will be assessed using incremental cost-effectiveness ratios.

DISCUSSION

Study findings will guide decision-making around how best to integrate mental health counselling into chronic disease care in a LMIC setting.

TRIAL REGISTRATION

Pan African Clinical Trials Registry, Trial registration number: ACTR201610001825403 . Registered 17 October 2016.

Patient preferences for the integration of mental health counseling and chronic disease care in South Africa

PURPOSE

To describe patient perceptions of the acceptability of integrating mental health counseling within primary care facilities in the Western Cape province of South Africa and their preferences for the way in which this care is delivered.

PATIENTS AND METHODS

Qualitative interviews with 30 purposively selected patients receiving treatment for HIV or diabetes within primary care facilities who screened positive for depression using the Center for Epidemiological Studies Depression Scale or hazardous alcohol use through the Alcohol Use Disorders Identification Test.

RESULTS

Participants articulated high levels of unmet need for mental health services and strong associations between poor mental health and the challenges of living with a chronic disease. Consequently, they considered it acceptable to offer screening and mental health counseling within the context of chronic disease care. They thought counseling would be highly relevant if it helped patients develop adaptive strategies for coping with stress and negative emotions. Irrespective of chronic disease, patients indicated a preference for lay counselors rather than existing clinicians as potential delivery agents, supporting a task-shared approach to mental health counseling delivery in primary care settings. Some expressed concern about the feasibility of using lay counselors already present in facilities to deliver this service, suggesting that additional counselors might be needed.

CONCLUSION

Findings demonstrate a need for mental health counseling within the context of chronic disease care in South Africa. Task-shared approaches, using lay counselors, seem acceptable to patients - provided counselors are selected to ensure they possess the qualities associated with effective counselors. Findings have informed the design of a task-shared mental health program that is responsive to the preferences of patients with chronic diseases.