Psychosocial Aspects of ART Counseling: A Comparison of HIV Beliefs and Knowledge in PMTCT and ART-Naïve Women

Generating fair, reliable, and accurate neuropsychological test norms for people with HIV in a low- or middle-income country

Effective neuropsychological assessment of people with HIV (PWH) in low- and middle-income countries (LMICs) is hampered by the unavailability of adequate test norms. We aimed to: (1) develop demographically-corrected (regression-based) South African (SA) normative data for an HIV appropriate neuropsychological test battery for Xhosa home-language speakers; (2) compare the utility of those norms to that of (i) internal standardization norms and (ii) US test publisher norms; and (3) determine the criterion validity of the newly-developed norms. 114 controls and 102 demographically comparable Xhosa home-language people living with HIV completed a well-establised, standard HIV neuropsychological test battery assessing seven cognitive domains. Using a common performance metric (z-score), we compared control and PWH test performance and examined the extent to which the three different normative datasets embedded demographic effects e.g., education. Using internal standardization norms, analyses detected medium-sized correlations of overall test performance with age and education. Correlations were fully corrected for by the newly-developed demographically-corrected norms. Using demographically-corrected norms, PWH performed significantly more poorly than controls in five cognitive domains, whereas using internal standardization norms and test-publisher norms, PWH performed significantly more poorly than controls in one and two domains, respectively. Demographically-corrected norms estimated 43.1% of PWH were cognitively impaired; these estimates were 22.5% using test-publisher norms and 19.6% using internal standardization norms. Demographically-corrected SA norms were more sensitive to cognitive impairment in PWH than the other sets of norms. Expansion of this regression-based method to create population-appropriate norms will benefit research and clinical practice in LMICs.

Assessment of an instrument scale measuring the knowledge of antiretroviral therapy among people living with HIV

BACKGROUND

Antiretroviral therapy (ART) is currently the most effective way to treat people living with human immunodeficiency virus (PLHs) and reduce HIV transmission. While there are many factors that reduce adherence to ART, PLHs' knowledge about ART may determine the level of adherence. It is necessary to design and assess an instrument scale that measures the knowledge of antiretroviral therapy among PLHs.

METHOD

A cross-sectional study was conducted among PLHs in Honghe Hani and Yi Autonomous Prefecture, China. Both exploratory and confirmatory factor analyses were used to examine the latent factors of antiretroviral therapy knowledge scale. Internal consistency was assessed separately for the scale and its dimensions by estimating Cronbach's alphas, split-half reliability and Spearman's correlation coefficient. ANOVAs were used to compare the scores of different dimensions with sociodemographic characteristics.

RESULTS

Four factors were extracted according to factor loadings. They had high internal consistency reliability (Cronbach's alpha: 0.70-0.95) and good construct validity (standardized factor loading range: 0.46-0.86) in the scale. Goodness of fit indices indicated that a four-factor solution fit the data at an accepted level (χ²/degree ratio = 1.980, RMSEA = 0.069, GFI = 0.909, CFI = 0.957, NFI = 0.917, TLI = 0.944). ANOVAs indicated that the score was higher among PLHs who were Han, had spouses/partners, were non-famers or migrant workers, initiated ART, and had a high school or above education.

CONCLUSION

The psychometric assessment indicated that this ART knowledge scale had accepted internal consistency and discriminant construct validity. It can be used to assess the knowledge of antiretroviral therapy for PLHs.

18-24-month HIV-free survival as measurement of the effectiveness of prevention of mother-to-child transmission in the context of lifelong antiretroviral therapy: Results of a community-based survey

Introduction

Population-based HIV-free survival at 18–24 months of age among HIV-exposed infants in high prevalence settings in the era of treatment for all is largely unknown. We conducted a community-based survey to determine outcomes of HIV-exposed infants at 18–24 months in Lesotho.

Methods

Between November 2015 and December 2016, we conducted a survey among households with a child born 18–24 months prior to data collection. Catchment areas from 25 health facilities in Butha-Buthe, Maseru, Mohale’s Hoek and Thaba-Tseka districts were randomly selected using probability proportional to size sampling. Consecutive households were visited and eligible consenting caregivers and children were enrolled.

Rapid HIV antibody testing was performed on mothers of unknown HIV status (never tested or tested HIV-negative >3 months prior) and their children, and to children born to known HIV-positive mothers. Information on demographics, health-seeking behavior, HIV, and mortality were captured for mothers and children, including those who died.

The difference in survival between subgroups was determined using the log-rank test.

Results

Of the 1,852 mothers/caregivers enrolled, 570 mothers were HIV-positive. The mother-to-child HIV transmission rate was 5.7% [95% CI: 4.0–8.0]. The mortality rate was 2.6% [95% CI: 1.6–4.2] among HIV-exposed children compared to 1.4% (95% CI: 0.9–2.3) among HIV-unexposed children. HIV-free survival was 91.8% [95% CI: 89.2–93.8] among HIV-exposed infants. Disclosure of mother’s HIV status (aOR = 4.9, 95% CI: 1.3–18.2) and initiation of cotrimoxazole prophylaxis in the child (aOR = 3.9, 95% CI: 1.2–12.6) were independently associated with increased HIV-free survival while child growth problems (aOR = 0.2, 95% CI: 0.09–0.5) were independently associated with reduced HIV-free survival.

Conclusion

Even in the context of lifelong antiretroviral therapy among pregnant and breastfeeding women, HIV has a significant effect on survival among HIV-exposed children compared to unexposed children. Lesotho has not reached elimination of HIV transmission from mother to child.

A culturally fair test of processing speed: Construct validity, preliminary normative data, and effects of HIV infection on performance in South African adults

OBJECTIVES

Impaired processing speed (PS) is a feature of cognitive profiles associated with neurological disorders particularly prevalent in low- or middle-income countries (LMICs). However, commonly used PS tests are not validated for use in LMICs. We assessed, using a sample of healthy South African adults, the construct validity of PS tests contained within NeuroScreen (a tablet-based application and test battery designed to be culturally fair), and established preliminary normative data for those tests (Study 1). Moreover, because South Africa has the highest population prevalence of people living with HIV and PS deficits are a core feature of HIV-associated cognitive impairment, we assessed whether NeuroScreen could detect PS impairment in a sample of HIV-infected South African adults (Study 2).

METHODS

In Study 1 (N = 112 healthy adults) and Study 2 (the Study 1 sample, plus n = 102 HIV-infected adults), we administered Neuroscreen and a standardized paper-and-pencil neuropsychological test battery.

RESULTS

In Study 1, factor analyses indicated that NeuroScreen PS scores loaded onto one factor and converged with scores on paper-and-pencil PS tests. Regression modeling indicated that age significantly predicted NeuroScreen PS performance (i.e., younger participants performed better). In Study 2, HIV-infected participants performed significantly more poorly on NeuroScreen PS tests than their HIV-uninfected counterparts. Moreover, a significantly larger proportion of HIV-infected participants displayed impaired PS when judged against the regression-based norms.

CONCLUSIONS

These results suggest that NeuroScreen has cross-cultural utility in assessing adult PS performance, and that it might be useful in tracking trajectories of PS decline within HIV infection. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Empowering Lay-Counsellors with Technology: Masivukeni, a Standardized Multimedia Counselling Support Tool to Deliver ART Counselling

Lay-counsellors in resource-limited settings convey critical HIV- and ART-information, and face challenges including limited training and variable application of counselling. This study explored lay-counsellors and Department of Health (DoH) perspectives on the utility of a multimedia adherence counselling program. Masivukeni, an mHealth application that provides scaffolding for delivering standardized ART counselling was used in a 3-year randomized control trail at two primary health care clinics in Cape Town, South Africa. In this programmatic and descriptive narrative report, we describe the application; lay-counsellors' response to open-ended questions regarding their experience with using Masivukeni; and perspectives of the City of Cape Town and Western Cape Government DoH, obtained through ongoing engagements and feedback sessions. Counsellors reported Masivukeni empowered them to provide high quality counselling. DoH indicated strong support for a future implementation study assessing feasibility for larger scale roll-out. Masivukeni has potential as a counselling tool in resource-limited settings.

A Mobile App to Screen for Neurocognitive Impairment: Preliminary Validation of NeuroScreen Among HIV-Infected South African Adults

Background

Neurocognitive impairment (NCI) is one of the most common complications of HIV infection, and has serious medical and functional consequences. South Africa has 7 million people living with HIV (PLHIV) with up to three-quarters of antiretroviral therapy (ART)-naïve individuals having NCI. South Africa’s health system struggles to meet the care needs of its millions of PLHIV; screening for NCI is typically neglected due to limited clinical staff trained to administer, score, and interpret neuropsychological tests, as well as long test batteries and limited screening tools for South African populations. Without accurate, clinically useful, and relatively brief NCI screening tests that can be administered by all levels of clinical staff, critical opportunities to provide psychoeducation, behavioral planning, additional ART adherence support, and adjuvant therapies for NCI (when they become available) are missed. To address these challenges and gap in care, we developed an mHealth app screening tool, NeuroScreen, to detect NCI that can be administered by all levels of clinical staff, including lay health workers.

Objective

The purpose of this study was to examine sensitivity and specificity of an adapted version of NeuroScreen to detect NCI (as determined by a gold standard neuropsychological test battery administered by a trained research psychometrist) among HIV-infected South Africans when administered by a lay health worker.

Methods

A total of 102 HIV-infected black South African adults who had initiated ART at least 12 months prior were administered NeuroScreen and a gold standard neuropsychological test battery in the participants’ choice of language (ie, English or isiXhosa). Three composite z scores were calculated for NeuroScreen: (1) sum of all individual test scores, (2) sum of all individual test scores and error scores from four tests, and (3) sum of four tests (abbreviated version). Global deficit scores were calculated for the gold standard battery where a score of 0.5 or greater indicated the presence of NCI.

Results

The mean age of participants was 33.31 (SD 7.46) years, most (59.8%, 61/102) had at least 12 years of education, and 81.4% (83/102) of the sample was female. Gold standard test battery results indicated that 26.5% (27/102) of the sample had NCI. Sensitivity and specificity of age-, education-, and sex-adjusted NeuroScreen scores were 81.48% and 74.67% for composite score 1, 81.48% and 81.33% for composite score 2, and 92.59% and 70.67% for composite score 3, respectively.

Conclusions

NeuroScreen, a highly automated, easy-to-use, tablet-based screening test to detect NCI among English- and isiXhosa-speaking South African HIV patients demonstrated robust sensitivity and specificity to detect NCI when administered by lay health workers. NeuroScreen could help make screening for NCI more feasible. However, additional research is needed with larger samples and normative test performance data are needed.