The social context of food insecurity among persons living with HIV/AIDS in rural Uganda

Food insecurity and its severity among adults receiving antiretroviral therapy in health facilities, northcentral Ethiopia: a multi-facility-based cross-sectional study

Background

Food insecurity plays a crucial role in predicting the spread of HIV due to the adverse effects of coping mechanisms adopted to mitigate it. However, there is a scarcity of context-specific evidence regarding food insecurity among HIV-infected adults. Therefore, this study aimed to assess the context-specific magnitude of food insecurity and associated factors among adults receiving antiretroviral therapy (ART) in health facilities in the North Shewa Zone, Ethiopia, ultimately contributing to the achievement of the 95-95-95 HIV treatment target in the local context.

Methods

A multi-facility cross-sectional study was conducted among 865 HIV-infected adults receiving ART and being followed up for their treatment. We included health facilities that provide ART, including four hospitals and six health centers. A log-binomial regression model was fitted to identify the association between food insecurity and independent variables. Adjusted prevalence ratios (APRs) with a 95% confidence interval were computed to measure the strength of the association.

Results

In this study, 290 (33.7, 95% CI: 30.60, 36.91) of the HIV-infected adults studied had food insecurity during their treatment and follow-up, of which 152 (52.41, 95% CI: 46.64, 58.13) and 110 (37.93%, CI: 32.50, 43.68) of them were found to have severe and moderate forms of food insecurity, respectively. We found that being younger (APR = 2.27, 95% CI: 1.12, 4.60), being female (APR = 1.87, 95% CI: 1.03, 3.39), lacking formal education (APR = 10.79, 95% CI: 14.74, 24.58), having lower educational status (APR = 5.99, 95% CI: 2.65, 13.54), being a daily laborer (APR = 6.90, 95% CI: 2.28, 20.85), having low monthly income (APR = 1.89, 95% CI: 1.11, 3.22), advanced WHO clinical stage (APR = 2.34, 95% CI: 1.08, 5.10), and receiving ART for less than 4 years (AOR = 2.28, 95% CI: 1.09, 4.74) were significantly associated with a high proportion of food insecurity among HIV-infected adults.

Conclusion

The magnitude of food insecurity among HIV-infected adults receiving ART was high, with an extremely high magnitude of severe food insecurity. The finding suggests the need for culture- and context-specific nutritional interventions to address the gender dynamics of food insecurity, attention to the early stage of ART, and the integration of strategies to improve educational status and enhance income-generation activities of HIV-infected adults. This requires an emphasis on the link between food insecurity and HIV in Ethiopia's national food and nutrition policy.

Caregiver preferences for physically harsh discipline of children in rural Uganda

Purpose

Physically harsh discipline is associated with poor developmental outcomes among children. These practices are more prevalent in areas experiencing poverty and resource scarcity, including in low- and middle-income countries. Designed to limit social desirability bias, this cross-sectional study in rural Uganda estimated caregiver preferences for physically harsh discipline; differences by caregiver sex, child sex, and setting; and associations with indicators of household economic stress and insecurity.

Method

Three-hundred-fifty adult caregivers were shown six hypothetical pictographic scenarios depicting children whining, spilling a drink, and kicking a caregiver. Girls and boys were depicted engaging in each of the three behaviors. Approximately half of the participants were shown scenes from a market setting and half were shown scenes from a household setting. For each scenario, caregivers reported the discipline strategy they would use (time out, beating, discussing, yelling, ignoring, slapping).

Results

Two thirds of the participants selected a physically harsh discipline strategy (beating, slapping) at least once. Women selected more physically harsh discipline strategies than men (b = 0.40; 95% confidence interval [CI], 0.26 to 0.54). Participants shown scenes from the market selected fewer physically harsh discipline strategies than participants shown scenes from the household (b = -0.51; 95% CI, -0.69 to -0.33). Finally, caregivers selected more physically harsh discipline strategies in response to boys than girls. Indicators of economic insecurity were inconsistently associated with preferences for physically harsh discipline.

Conclusions

The high prevalence of physically harsh discipline preferences warrant interventions aimed at reframing caregivers' approaches to discipline.

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

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

HIV Vulnerabilities Associated with Water Insecurity, Food Insecurity, and Other COVID-19 Impacts Among Urban Refugee Youth in Kampala, Uganda: Multi-method Findings

Food insecurity (FI) and water insecurity (WI) are linked with HIV vulnerabilities, yet how these resource insecurities shape HIV prevention needs is understudied. We assessed associations between FI and WI and HIV vulnerabilities among urban refugee youth aged 16-24 in Kampala, Uganda through individual in-depth interviews (IDI) (n = 24), focus groups (n = 4), and a cross-sectional survey (n = 340) with refugee youth, and IDI with key informants (n = 15). Quantitative data was analysed via multivariable logistic and linear regression to assess associations between FI and WI with: reduced pandemic sexual and reproductive health (SRH) access; past 3-month transactional sex (TS); unplanned pandemic pregnancy; condom self-efficacy; and sexual relationship power (SRP). We applied thematic analytic approaches to qualitative data. Among survey participants, FI and WI were commonplace (65% and 47%, respectively) and significantly associated with: reduced SRH access (WI: adjusted odds ratio [aOR]: 1.92, 95% confidence interval [CI]: 1.19-3.08; FI: aOR: 2.31. 95%CI: 1.36-3.93), unplanned pregnancy (WI: aOR: 2.77, 95%CI: 1.24-6.17; FI: aOR: 2.62, 95%CI: 1.03-6.66), and TS (WI: aOR: 3.09, 95%CI: 1.22-7.89; FI: aOR: 3.51, 95%CI: 1.15-10.73). WI participants reported lower condom self-efficacy (adjusted β= -3.98, 95%CI: -5.41, -2.55) and lower SRP (adjusted β= -2.58, 95%CI= -4.79, -0.37). Thematic analyses revealed: (1) contexts of TS, including survival needs and pandemic impacts; (2) intersectional HIV vulnerabilities; (3) reduced HIV prevention/care access; and (4) water insecurity as a co-occurring socio-economic stressor. Multi-method findings reveal FI and WI are linked with HIV vulnerabilities, underscoring the need for HIV prevention to address co-occurring resource insecurities with refugee youth.

Mediating role of food insecurity in the relationship between perceived MSM related stigma and depressive symptoms among men who have sex with men in Nepal

BACKGROUND

Previous studies have indicated the association between stigma and depressive symptoms among frequently stigmatized groups, such as men who have sex with men (MSM). While this association has been suggested in the literature, there is a dearth of evidence that examines whether food insecurity statistically mediates the relationship between stigma and depressive symptoms.

METHODS

This cross-sectional study conducted between October and December 2022 among a sample of 250 MSM in Kathmandu, Nepal, recruited through respondent-driven sampling. An unadjusted model including the exposure (stigma), mediator (food insecurity), and outcome variables (depressive symptoms) and an adjusted model that controlled for sociodemographic, behavioral, and health-related confounders were used. Bootstrapping was utilized to estimate the coefficients of these effects and the corresponding 95% confidence intervals. Via bootstrap approach, we find out the mediating role of food insecurity in the association between stigma and depressive symptoms.

RESULTS

Depressive symptoms, stigma, and food insecurity were 19.6%, 24.4%, and 29.2%, respectively, among MSM. Food insecurity was associated with higher age (b = 0.094; 95% CI = 0.039, 0.150) and monthly income (b = -1.806; 95% CI = -2.622, -0.985). Depressive symptoms were associated with condom-less sex in past six months (b = -1.638; 95% CI = -3.041, -0.092). Stigma was associated with higher age (b = 0.196; 95% CI = 0.084, 0.323) and PrEP uptake (b = 2.905; 95% CI = 0.659. 5.248). Food insecurity statistically mediated 20.6% of the indirect effect of stigma in depressive symptoms.

CONCLUSION

Our findings show that food insecurity affects the relationship between stigma and depressive symptoms in this population. Reducing food insecurity and addressing the stigma surrounding sexual orientation should be a priority when addressing mental health concerns among MSM in Nepal and other resource-limited countries with similar socio-cultural settings.

Exploring feasibility and acceptability of an integrated urban gardens and peer nutritional counselling intervention for people with HIV in the Dominican Republic

OBJECTIVE

Food security interventions with people living with HIV (PLHIV) are needed to improve HIV outcomes. This process evaluation of a pilot intervention involving urban gardening and peer nutritional counselling with PLHIV assesses feasibility, acceptability and implementation challenges to inform scale-up.

DESIGN

Mixed methods were used, including quantitative data on intervention participation and feasibility and acceptability among participants (n 45) and qualitative data from a purposive sample of participants (n 21). Audio-recorded interviews were transcribed and coded using a codebook developed iteratively.

SETTING

An HIV clinic in the northwest-central part of the Dominican Republic.

RESULTS

The intervention was feasible for most participants: 84 % attended a garden workshop and 71 % established an urban garden; 91 % received all three core nutritional counselling sessions; and 73 % attended the cooking workshop. The intervention was also highly acceptable: nearly, all participants (93-96 %) rated the gardening as 'helpful' or 'very helpful' for taking HIV medications, their mental/emotional well-being and staying healthy; similarly, high percentages (89-97 %) rated the nutrition counselling 'helpful' or 'very helpful' for following a healthy diet, reducing unhealthy foods and increasing fruit/vegetable intake. Garden barriers included lack of space and animals/pests. Transportation barriers impeded nutritional counselling. Harvested veggies were consumed by participants' households, shared with neighbours and family, and sold in the community. Many emphasised that comradery with other PLHIV helped them cope with HIV-related marginalisation.

CONCLUSION

An urban gardens and peer nutritional counselling intervention with PLHIV was feasible and acceptable; however, addressing issues of transportation, pests and space is necessary for equitable participation and benefit.

Food Insecurity and Transmission Risks Among People with HIV Who Use Substances

Food insecurity (FI) impacts people with HIV (PWH) and those who use substances (i.e. drugs and alcohol). We evaluated the longitudinal association between FI and HIV transmission risks (unprotected sexual contacts and shared needles/syringes). Among 351 PWH who use substances in Russia, 51.6% reported FI and 37.0% past month injection drug use. The mean number of unprotected sexual contacts in the past 90 days was 13.4 (SD 30.1); 9.7% reported sharing needles/syringes in the past month. We did not find a significant association between mild/moderate FI (adjusted IRR = 0.87, 95% CI 0.47, 1.61) or severe FI (aIRR = 0.84, 95% CI 0.46, 1.54; global p = 0.85) and unprotected sexual contacts. We observed a significant association between severe FI and sharing needles/syringes in the past month (adjusted OR = 3.27, 95% CI 1.45, 7.39; p = 0.004), but not between mild/moderate FI and sharing needles/syringes in the past month (aOR = 1.40,95% CI 0.58, 3.38; p = 0.45). These findings suggest that severe FI could be a potential target for interventions to lower HIV transmission.

Correlates of Internalized HIV Stigma: A Comprehensive Systematic Review

Internalized HIV stigma is prevalent and research on internalized HIV stigma has increased during the past 10 years. The aim of this systematic review was to synthesize research on internalized HIV stigma and relationships with various health-related variables in order to better inform the development of interventions aimed at reducing internalized HIV stigma. We reviewed 176 studies with a quantitative design reporting correlates that were peer-reviewed, published in English before January 2021, drawn from PubMed, PSYCHINFO, Web of Science, EBSCO, and Scopus. Synthesis showed consistent associations between internalized stigma and negative psychological (e.g., depression, anxiety), social (e.g., lack of social support, discrimination, nondisclosure, and intersecting stigmas), and health (e.g., substance use, treatment nonadherence, negative clinical HIV outcomes) variables. We argue for a more socioecological approach to internalized stigma, with greater attention for intersectional stigmas, and more longitudinal research, if we are to effectively develop interventions that reduce internalized stigma.

Prevalence and factors associated with psychological distress among pregnant and non-pregnant youth living with HIV in rural Uganda: a comparative study

Youth living with HIV (YLHIV) are prone to psychological distress, which may have detrimental effects on health outcomes. Pregnant youth have poor access to HIV care increasing the risk of vertical transmission of HIV to their infants. Both HIV and pregnancy are independently associated with poor mental health among adolescents. The factors that predispose women to poor mental health may also increase their risk of contracting HIV. Despite their desire to have children YLHIV are at a high risk of psychological distress. However, factors associated with psychological distress among YLHIV in rural Uganda are not well explored. Therefore, the purpose of this study was to determine the prevalence of, and factors associated with psychological distress among pregnant and non-pregnant YLHIV in south western Uganda. We enrolled 224 YLHIV aged 15-24 years both pregnant and nonpregnant (ratio 1:1) between December 2018 and March 2019. We obtained information on psychological distress and factors hypothesized to affect mental health outcomes among people living with HIV including internalized HIV stigma, intimate partner violence, self-esteem and social support. Bivariate and multivariable logistic regression analysis were used to estimate factors independently associated with psychological distress. The prevalence of psychological distress was 48.2%% among pregnant YLHIV and 32.14% among non-pregnant YLHIV. Factors significantly associated with psychological distress among pregnant YLHIV were HIV stigma (AOR=4.61; 95% CI 1.63-13.84; P=0.004), physical abuse (AOR=4.97; 95% CI 1.41- 17.56; P= 0.013), and separation from partner (AOR =0.03; 95% CI 0.001-0.580; P=0.020).

High PrEP uptake and objective longitudinal adherence among HIV-exposed women with personal or partner plans for pregnancy in rural Uganda: A cohort study

BACKGROUND

In Uganda, fertility rates and adult HIV prevalence are high, and many women conceive with partners living with HIV. Pre-exposure prophylaxis (PrEP) reduces HIV acquisition for women and, therefore, infants. We developed the Healthy Families-PrEP intervention to support PrEP use as part of HIV prevention during periconception and pregnancy periods. We conducted a longitudinal cohort study to evaluate oral PrEP use among women participating in the intervention.

METHODS AND FINDINGS

We enrolled HIV-negative women with plans for pregnancy with a partner living, or thought to be living, with HIV (2017 to 2020) to evaluate PrEP use among women participating in the Healthy Families-PrEP intervention. Quarterly study visits through 9 months included HIV and pregnancy testing and HIV prevention counseling. PrEP was provided in electronic pillboxes, providing the primary adherence measure ("high" adherence when pillbox was opened ≥80% of days). Enrollment questionnaires assessed factors associated with PrEP use. Plasma tenofovir (TFV) and intraerythrocytic TFV-diphosphate (TFV-DP) concentrations were determined quarterly for women who acquired HIV and a randomly selected subset of those who did not; concentrations TFV ≥40 ng/mL and TFV-DP ≥600 fmol/punch were categorized as "high." Women who became pregnant were initially exited from the cohort by design; from March 2019, women with incident pregnancy remained in the study with quarterly follow-up until pregnancy outcome. Primary outcomes included (1) PrEP uptake (proportion who initiated PrEP); and (2) PrEP adherence (proportion of days with pillbox openings during the first 3 months following PrEP initiation). We used univariable and multivariable-adjusted linear regression to evaluate baseline predictors selected based on our conceptual framework of mean adherence over 3 months. We also assessed mean monthly adherence over 9 months of follow-up and during pregnancy. We enrolled 131 women with mean age 28.7 years (95% CI: 27.8 to 29.5). Ninety-seven (74%) reported a partner with HIV and 79 (60%) reported condomless sex. Most women (N = 118; 90%) initiated PrEP. Mean electronic adherence during the 3 months following initiation was 87% (95% CI: 83%, 90%). No covariates were associated with 3-month pill-taking behavior. Concentrations of plasma TFV and TFV-DP were high among 66% and 47%, 56% and 41%, and 45% and 45% at months 3, 6, and 9, respectively. We observed 53 pregnancies among 131 women (1-year cumulative incidence 53% [95% CI: 43%, 62%]) and 1 HIV-seroconversion in a non-pregnant woman. Mean pillcap adherence for PrEP users with pregnancy follow-up (N = 17) was 98% (95% CI: 97%, 99%). Study design limitations include lack of a control group.

CONCLUSIONS

Women in Uganda with PrEP indications and planning for pregnancy chose to use PrEP. By electronic pillcap, most were able to sustain high adherence to daily oral PrEP prior to and during pregnancy. Differences in adherence measures highlight challenges with adherence assessment; serial measures of TFV-DP in whole blood suggest 41% to 47% of women took sufficient periconception PrEP to prevent HIV. These data suggest that women planning for and with pregnancy should be prioritized for PrEP implementation, particularly in settings with high fertility rates and generalized HIV epidemics. Future iterations of this work should compare the outcomes to current standard of care.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03832530 https://clinicaltrials.gov/ct2/show/NCT03832530?term=lynn+matthews&cond=hiv&cntry=UG&draw=2&rank=1.

Associations of the COVID-19 pandemic with quality of life: A cross-sectional study of older-age people with and without HIV in rural Uganda

Background

COVID-19-related lockdowns and other public health measures may have differentially affected the quality of life (QOL) of older people with and without human immunodeficiency virus (HIV) in rural Uganda.

Methods

The Quality of Life and Aging with HIV in Rural Uganda study enrolled people with and without HIV aged over 49 from October 2020 to October 2021. We collected data on COVID-19-related stressors (behavior changes, concerns, interruptions in health care, income, and food) and the participants' QOL. We used linear regression to estimate the associations between COVID-19-related stressors and QOL, adjusting for demographic characteristics, mental and physical health, and time before vs after the lockdown during the second COVID-19 wave in Uganda. Interaction between HIV and COVID-19-related stressors evaluated effect modification.

Results

We analyzed complete data from 562 participants. Mean age was 58 (standard deviation (SD) = 7); 265 (47%) participants were female, 386 (69%) were married, 279 (50%) had HIV, and 400 (71%) were farmers. Those making ≥5 COVID-19-related behavior changes compared to those making ≤2 had worse general QOL (estimated linear regression coefficient (b) = - 4.77; 95% confidence interval (CI) = -6.61, -2.94) and health-related QOL (b = -4.60; 95% CI = -8.69, -0.51). Having access to sufficient food after the start of the COVID-19 pandemic (b = 3.10, 95% CI = 1.54, 4.66) and being interviewed after the start of the second lockdown (b = 2.79, 95% CI = 1.30, 4.28) were associated with better general QOL. Having HIV was associated with better health-related QOL (b = 5.67, 95% CI = 2.91,8.42). HIV was not associated with, nor did it modify the association of COVID-19-related stressors with general QOL.

Conclusions

In the context of the COVID-19 pandemic in an HIV-endemic, low-resource setting, there was reduced QOL among older Ugandans making multiple COVID-19 related behavioral changes. Nonetheless, good QOL during the second COVID-19 wave may suggest resilience among older Ugandans.

The Impact of Land Tenure Security on a Livelihood Intervention for People Living with HIV in Western Kenya

Few studies have explored land access, a structural driver of health, and women's participation in livelihood interventions to improve food security and HIV outcomes. This qualitative study, embedded within Shamba Maisha (NCT02815579)-a randomized controlled trial (RCT) examining the impact of a multisectoral intervention among farmers living with HIV in western Kenya-sought to explore the influence of perceived access to and control of land on agricultural productivity, investments, and benefits. Thirty in-depth interviews (IDIs) were conducted with purposively sampled men and women, 3 to 6 months after receiving intervention inputs; data were deductively and inductively coded and analyzed. Farming practices and participation in Shamba Maisha were dependent on land tenure and participants' perceived strength of claim over their land, with participants who perceived themselves to be land insecure less likely to make long-term agricultural investments. Land tenure was influenced by a number of factors and posed unique challenges for women which negatively impacted uptake and success in the intervention. Data underscore the importance of secure land tenure for the success of similar interventions, especially for women; future interventions should integrate land security programming for improved outcomes for all.

How food support improves mental health among people living with HIV: A qualitative study

BACKGROUND

Food insecurity is associated with poor mental health among people living with HIV (PLHIV). This qualitative study explored the mental health experiences of PLHIV participating in a medically appropriate food support program.

METHODS

Semi-structured interviews were conducted post-intervention (n = 34). Interview topics included changes, or lack thereof, in mental health and reasons for changes. Interviews were audio-recorded, transcribed, and double-coded. Salient themes were identified using an inductive-deductive method.

RESULTS

Positive changes in mental health self-reported by PLHIV included improved mood and reduced stress, worry, and anxiety. Participants attributed these changes to: 1) increased access to sufficient and nutritious foods, 2) increased social support, 3) reduced financial hardship, 4) increased sense of control and self-esteem, and 5) reduced functional barriers to eating.

CONCLUSIONS

Medically appropriate food support may improve mental health for some PLHIV. Further work is needed to understand and prevent possible adverse consequences on mental health after programs end.

Adverse childhood experiences, alcohol consumption, and the modifying role of social participation: population-based study of adults in southwestern Uganda

Background

Adverse childhood experiences (ACEs) include multiple forms of child maltreatment, including abuse and neglect, as well as other forms of household dysfunction. Studies from Uganda have revealed a high prevalence of child abuse, as well as one of the highest levels of alcohol consumption in Africa. Few population-based studies from Africa have estimated associations between ACEs and adult alcohol use, or assessed the potential buffering effects of social participation.

Methods

This cross-sectional, population-based study was conducted in a rural parish in southwestern Uganda between 2016 and 2018. We assessed self-reported ACEs using a modified version of the Adverse Childhood Experiences - International Questionnaire (ACE-IQ) scale. We measured heavy alcohol consumption using a 3-item scale previously validated in this population. We measured social participation using a 10-item scale eliciting participants' membership and participation in different community groups over the past two months. We fitted multivariable Poisson regression models to estimate the associations between ACEs and heavy alcohol consumption, and to assess for the potential buffering effects of social participation.

Results

We estimated statistically significant associations between the total ACE score and heavy alcohol consumption (adjusted relative risk [ARR] per ACE=1.17; 95% CI, 1.09-1.25; P ≤0.001). Social participation had a statistically significant moderating effect on the association between total ACE score and heavy alcohol consumption (P=0.047 for interaction): the estimated association between total ACE score and heavy alcohol consumption among study participants who did not participate in a community group was larger, with a narrower confidence interval (ARR=1.21 per ACE; 95% CI, 1.11-1.33; P<0.001), while the estimated association among study participants who did participate in a community group was smaller and less precisely estimated (ARR=1.12 per ACE; 95% CI, 1.02-1.24; P=0.02).

Conclusions

Our findings demonstrate an association between ACEs and heavy alcohol consumption behavior among adults in rural Uganda. The adverse effects of ACEs were buffered in part by social participation. To prevent or reduce harmful alcohol use behaviors among adults, it is important to address the chronic stress caused by ACEs.

Social network of malnourished children and its association with family’s food and nutritional security

Abstract Objectives: evaluate the relationship between family’s food and nutrition insecurity (FNI) and the social network of malnourished children. Methods: cross-sectional study with 92 children, included in the economic class D-E. For the analysis of the children’s social network, the mothers answered four simple questions. To investigate the FNI, the Brazilian Scale of Food Insecurity was used. The association between variables was analyzed by Poisson regression with robust analysis of variances. Results: 56.5% of the children had a weak social network (<10 individuals), and the prevalence of FNI was 72.8%. An inverse association was observed between children of the daily social network and FNI family (OR=0.94; CI95%=0.89-0.99], p=0.03). The number of individuals in the children’s daily social network was negatively associated with the likelihood of FNI. The mother’s educational level was also related to FNI (OR=2.20 [CI95%=1.11-4.34]; p=0.02), being the child up to 2.2 times more likely to be in FNI when the mother has less than four years of study. Conclusion: these results suggest that social network is associated with the FNI of malnourished children. Interventions designed to strengthen instrumental and other forms of support among small social networks can improve the health/nutrition of malnourished children with FNI.

Social network correlates of free and purchased insecticide-treated bed nets in rural Uganda

BACKGROUND

Malaria is a major cause of mortality and morbidity in Uganda. Despite Uganda's efforts to distribute bed nets, only half of households have achieved the World Health Organization (WHO) Universal Coverage Criteria (one bed net for every two household members). The role of peer influence on bed net ownership remains underexplored. Data on the complete social network of households were collected in a rural parish in southwestern Uganda to estimate the association between household bed net ownership and peer household bed net ownership.

METHODS

Data on household sociodemographics, bed net ownership, and social networks were collected from all households across one parish in southwestern Uganda. Bed nets were categorized as either purchased or free. Purchased and free bed net ownership ratios were calculated based on the WHO Universal Coverage Criteria. Using network name generators and complete census of parish residents, the complete social network of households in the parish was generated. Linear regression models that account for network autocorrelation were fitted to estimate the association between households' bed net ownership ratios and bed net ownership ratios of network peer households, adjusting for sociodemographics and network centrality.

RESULTS

One thousand seven hundred forty-seven respondents were interviewed, accounting for 716 households. The median number of peer households to which a household was directly connected was 7. Eighty-six percent of households owned at least one bed net, and 41% of households met the WHO Universal Coverage Criterion. The median bed net ownership ratios were 0.67 for all bed nets, 0.33 for free bed nets, and 0.20 for purchased bed nets. In adjusted multivariable models, purchased bed net ownership ratio was associated with average household wealth among peer households (b = 0.06, 95% CI 0.03, 0.10), but not associated with average purchased bed net ownership ratio of peer households. Free bed net ownership ratio was associated with the number of children under 5 (b = 0.08, 95% CI 0.05, 0.10) and average free bed net ownership ratios of peer households (b = 0.66, 95% CI 0.46, 0.85).

CONCLUSIONS

Household bed net ownership was associated with bed net ownership of peer households for free bed nets, but not for purchased bed nets. The findings suggest that public health interventions may consider leveraging social networks as tools for dissemination, particularly for bed nets that are provided free of charge.

Exploring antiretroviral therapy adherence, competing needs, and viral suppression among people living with HIV and food insecurity in the Dominican Republic

Understanding factors related to suboptimal adherence to antiretroviral therapy (ART) and detectable viral load (VL), especially among vulnerable populations, is needed to improve HIV outcomes. The Caribbean is highly impacted by HIV and socioeconomic inequalities, but few studies have been conducted there to explore food insecurity among people with HIV and factors associated with viral suppression in this vulnerable population. Using baseline data from a pilot intervention trial among people living with HIV and food insecurity in the Dominican Republic, we examined psychosocial and behavioral factors associated with viral suppression, ART adherence, and competing needs. Among participants (n = 115), 61% had a detectable VL; the strongest factor associated with detectable VL was having missed taking ART in the last six months due to not having food (OR = 2.68, p = 0.02). Greater odds of reporting missed ART doses due to not having food were associated with severe food insecurity (OR = 4.60, p = 0.006), clinical depression (OR = 2.76, p = 0.018), Haitian background (OR = 6.62 p = 0.017), and internalized HIV stigma (OR = 1.09, p = 0.041), while lower odds were associated with social support (OR = 0.89, p = 0.03) and having health insurance (OR = 0.27, p = 0.017). Ensuring that people with HIV and food insecurity have food to take with their ART is essential for viral suppression.

Addressing the Syndemics of HIV, Mental Health, and COVID-19 Using the Health and Human Rights Framework among Youth Living with HIV, in Uganda: an Interpretive Phenomenological Study

Stigma and discrimination negatively impact the prevention, treatment, and care of HIV. The COVID-19 pandemic increased this complexity and created a cluster of synergistic health contexts, wherein the physiological aspects of HIV and the social and environmental conditions increased the vulnerability in health outcomes for youth living with HIV (YPLHIV) in Kampala, Uganda. We used interpretive phenomenological analysis (IPA) and the syndemics framework to understand the lived experiences of YPLHIV. From December 2020 to May 2021, six qualitative focus groups were held with 31 youth living with HIV to understand the lived experiences of YPLHIV. The guided questions used were audio-recorded, transcribed verbatim, and coded for thematic analysis. Findings highlight the complexity of intersecting stigma of HIV and COVID-19 that have worsened antiretroviral treatment adherence and mental health issues due to lack of access to critical needs such as fears of food insecurity, health-related worries, the fear of perishing due to COVID-19, and human rights concerns related to gender and sexual identity. The study recommends addressing human rights-related concerns in addition to health-related concerns to comprehensively mitigate the syndemics of HIV and COVID-19 for YPLHIV in Uganda.

Continued attendance in a PrEP program despite low adherence and non-protective drug levels among adolescent girls and young women in Kenya: Results from a prospective cohort study

BACKGROUND

In sub-Saharan Africa (SSA), adolescent girls and young women (AGYW) ages 15 to 24 years represent <10% of the population yet account for 1 in 5 new HIV infections. Although oral pre-exposure prophylaxis (PrEP) with tenofovir disoproxil fumarate/emtricitabine (TDF/FTC) can be highly effective, low persistence in PrEP programs and poor adherence have limited its ability to reduce HIV incidence among women.

METHODS AND FINDINGS

A total of 336 AGYW participating in the PEPFAR-funded DREAMS PrEP program in western Kenya were enrolled into a study of PrEP use conducted between 6/2019 to 1/2020. AGYW, who used daily oral TDF/FTC, completed interviews and provided dried blood spots (DBS) for measurement of tenofovir-diphosphate (TFV-DP) concentrations at enrollment and 3 months later, and 176/302 (58.3%, 95% confidence interval [95% CI 52.3 to 63.8]) met our definition of PrEP persistence: having expressed intention to use PrEP and attended both the second interview and an interim refill visit. Among AGYW with DBS taken at the second interview, only 9/197 (4.6%, [95% CI 1.6 to 7.5]) had protective TFV-DP levels (≥700 fmol/punch) and 163/197 (82.7%, [95% CI 77.5 to 88]) had levels consistent with no recent PrEP use (<10 fmol/punch). Perception of being at moderate-to-high risk for HIV if not taking PrEP was associated with persistence (adjusted odds ratio, 10.17 [95% CI 5.14 to 20.13], p < 0.001) in a model accounting for county of residence and variables that had p-value <0.1 in unadjusted analysis (age, being in school, initiated PrEP 2 to 3 months before the first interview, still active in DREAMS, having children, having multiple sex partners, partner aware of PrEP use, partner very supportive of PrEP use, partner has other partners, AGYW believes that a partner puts her at risk, male condom use, injectable contraceptive use, and implant contraceptive use). Among AGYW who reported continuing PrEP, >90% indicated they were using PrEP to prevent HIV, although almost all had non-protective TFV-DP levels. Limitations included short study duration and inclusion of only DREAMS participants.

CONCLUSIONS

Many AGYW persisted in the PrEP program without taking PrEP frequently enough to receive benefit. Notably, AGYW who persisted had a higher self-perceived risk of HIV infection. These AGYW may be optimal candidates for long-acting PrEP.

Implementation of Electronic Adherence Monitors and Associated Interventions for Routine HIV Antiretroviral Therapy in Uganda: Promising Findings

Background

High, sustained adherence is critical for achieving the individual and public health benefits of HIV antiretroviral therapy (ART). Electronic monitors provide detailed adherence information and can enable real-time interventions; however, their use to date has largely been confined to research. This pilot study (NCT03825952) sought to understand feasibility and acceptability a relatively low-cost version of this technology and associated interventions for routine ART delivery in sub-Saharan Africa.

Methods

We provided two ART clinics in rural, southwestern Uganda with electronic adherence monitors for data-informed counseling as well as optional SMS messages to clients and/or social supporters (daily or triggered by missed or delayed doses) and/or an alarm. Clinic and ART client experiences were observed for 3 months per client, including time and motion studies. Qualitative interviews among clients, clinicians, and healthcare administrators were informed by the Consolidated Framework for Implementation Research.

Results

Fifty-one ART clients were enrolled; 57% were male and the median age was 34 years. Choice of associated intervention varied among participants. The median number of visits during follow-up was two per client. Counselors reviewed the adherence data with 90% of clients at least once; 67% reviewed data at all visits. Average adherence was 94%; four clients had adherence gaps >1 week. Acceptability was high; all but one client found the monitor "very useful” and all found SMS “very useful.” Clinic visits among clients with the intervention lasted 4 min longer on average than those in standard care. The monitors and daily SMS generally functioned well, although excess SMS were triggered, primarily due to cellular network delays. Overall, participants felt the technology improved adherence, clinic experiences, and clinician-client relationships. Few worried about stigma and privacy. Cost was a concern for implementation, particularly at scale.

Conclusion

We successfully implemented a relatively low-cost electronic ART adherence monitor and associated interventions for routine care in rural Uganda. Feasibility and acceptability were generally high, and individuals were identified who could benefit from adherence support. Future work should involve longitudinal follow-up of diverse populations, clinical outcomes, and detailed cost-effectiveness analysis to help drive policy decisions around the uptake of this technology for routine clinical care.

Clinical Trial Registration

identifier: NCT03825952.

Relative Risk of Intimate Partner Violence According to Access to Instrumental Social Support Among Pregnant Women in Eswatini Whose Partners Do and Do Not Drink Alcohol

Intimate partner violence (IPV) affects one in three women around the world and is the tenth leading cause of death for women in Africa aged 15 to 29 years. Partner alcohol use, access to social support, and poverty all affect women's likelihood of experiencing violence. We sought to understand how partner alcohol use differentially affected the hypothesized association between a protective role of instrumental social support (in the form of food or financial loans) against IPV for a clinic-based sample of women in the Kingdom of Eswatini (formerly known as Swaziland). We use cross-sectional data from a parent study of women recruited from urban and rural antenatal clinics in Eswatini (n = 393) to calculate the association between experiencing IPV and perception of one's ability access to large cash loans, small cash loans, and food loans-both for the full sample and stratified by partner alcohol use. In fully adjusted models, the perception that one could access loans of food or money was associated with decreased relative risk of IPV for all women. These associations were modified by partner alcohol use. Access to instrumental support (loans of food or money) is associated with decreased risk of IPV, but this association varies according to the type of loan and whether or not a woman's partner drinks alcohol. Economic empowerment interventions to reduce IPV must be carefully tailored to ensure they are appropriate for a woman's specific individual, relationship, and community context.

Does resource insecurity drive HIV-related stigma? Associations between food and housing insecurity with HIV-related stigma in cohort of women living with HIV in Canada

INTRODUCTION

Women living with HIV across global contexts are disproportionately impacted by food insecurity and housing insecurity. Food and housing insecurity are resource insecurities associated with poorer health outcomes among people living with HIV. Poverty, a deeply stigmatized phenomenon, is a contributing factor towards food and housing insecurity. HIV-related stigma-the devaluation, mistreatment and constrained access to power and opportunities experienced by people living with HIV-intersects with structural inequities. Few studies, however, have examined food and housing insecurity as drivers of HIV-related stigma. This study aimed to estimate the associations between food and housing insecurity with HIV-related stigma among women living with HIV in Canada.

METHODS

This prospective cohort study of women living with HIV (≥16 years old) in three provinces in Canada involved three waves of surveys collected at 18-month intervals between 2013 and 2018. To understand associations between food and housing security and HIV-related stigma, we conducted linear mixed effects regression models. We adjusted for socio-demographic characteristics associated with HIV-related stigma.

RESULTS AND DISCUSSION

Among participants (n = 1422), more than one-third (n = 509; 36%) reported baseline food insecurity and approximately one-tenth (n = 152, 11%) housing insecurity. Mean HIV-related stigma scores were consistent across waves 1 (mean [M] = 57.2, standard deviation [SD] = 20.0, N = 1401) and 2 (M = 57.4, SD = 19.0, N = 1227) but lower at wave 3 (M = 52.8, SD = 18.7, N = 918). On average, across time, food insecure participants reported HIV-related stigma scores that were 8.6 points higher (95% confidence interval [CI]: 6.4, 10.8) compared with food secure individuals. Similarly, participants reporting insecure housing at wave 1 tended to experience greater HIV-related stigma (6.2 points, 95% CI: 2.7, 9.6) over time compared to stably housed participants. There was an interaction between time and housing insecurity, whereby baseline housing insecurity was no longer associated with higher HIV-related stigma at the third wave.

CONCLUSIONS

Among women living with HIV in Canada, experiencing food and housing insecurity was associated with consistently higher levels of HIV-related stigma. In addition to the urgent need to tackle food and housing insecurity among people living with HIV to optimize wellbeing, getting to the heart of HIV-related stigma requires identifying and dismantling resource insecurity-related stigma drivers.

Prevalence and predictors of food insecurity among people living with and without HIV in the African Cohort Study

OBJECTIVE

We determined the prevalence and identified predictors of food insecurity in four African countries.

DESIGN

Cross-sectional analyses at study enrolment.

SETTING

From January 2013 to March 2020, people living with HIV (PLWH) and without HIV were enrolled at twelve clinics in Kenya, Uganda, Tanzania and Nigeria.

PARTICIPANTS

Participants reporting not having enough food to eat over the past 12 months or receiving <3 meals/d were defined as food insecure. Robust Poisson regression models were used to estimate unadjusted and adjusted prevalence ratios (aPR) and 95 % CI for predictors of food insecurity among all participants and separately among PLWH.

RESULTS

1694/3496 participants (48·5 %) reported food insecurity at enrolment, with no difference by HIV status. Food insecurity was more common among older participants (50+ v. 18-24 years aPR 1·35, 95 % CI 1·15, 1·59). Having 2-5 (aPR 1·14, 95 % CI 1·01, 1·30) or >5 dependents (aPR 1·17, 95 % CI 1·02, 1·35), and residing in Kisumu West, Kenya (aPR 1·63, 95 % CI 1·42, 1·87) or Nigeria (aPR 1·20, 95 % CI 1·01, 1·41) was associated with food insecurity. Residing in Tanzania (aPR 0·65, 95 % CI 0·53, 0·80) and increasing education (secondary/above education v. none/some primary education aPR 0·73, 95 % CI 0·66, 0·81) was protective against food insecurity. Antiretroviral therapy (ART)-experienced PLWH were more likely to be food secure irrespective of viral load.

CONCLUSION

Food insecurity was highly prevalent in our cohort though not significantly associated with HIV. Policies aimed at promoting education, elderly care, ART access in PLWH and financial independence could potentially improve food security in Africa.

Economic, social and demographic impacts of drought on treatment adherence among people living with HIV in rural South Africa: A qualitative analysis

The 2015 El Niño-triggered drought in Southern Africa caused widespread economic and livelihood disruption in South Africa, imposing multiple physical and health challenges for rural populations including people living with HIV (PLHIV). We examined the economic, social and demographic impacts of drought drawing on 27 in-depth interviews in two cohorts of PLHIV in Hlabisa, uMkhanyakude district, KwaZulu-Natal. Thematic analysis revealed how drought-enforced soil water depletion, dried-up rivers, and dams culminated in a continuum of events such as loss of livestock, reduced agricultural production, and insufficient access to water and food which was understood to indirectly have a negative impact on HIV treatment adherence. This was mediated through disruptions in incomes, livelihoods and food systems, increased risk to general health, forced mobility and exacerbation of contextual vulnerabilities linked to poverty and unemployment. The systems approach, drawn from interview themes, hypothesises the complex pathways of plausible networks of impacts from drought through varying socioeconomic factors, exacerbating longstanding contextual precarity, and ultimately challenging HIV care utilisation. Understanding the multidimensional relationships between climate change, especially drought, and poor HIV care outcomes through the prism of contextual vulnerabilities is vital for shaping policy interventions.

Understanding the Effect of a Healthcare Provider-Led Family Planning Support Intervention on Contraception use and Pregnancy Desires among Postpartum Women Living with HIV in Southwestern Uganda

Modern contraceptive prevalence among women living with HIV (WLWH) in Uganda is still low at 45%, and up to a third of women are likely to discontinue the method within the first year of initiation. This increases risks of unplanned pregnancies, perinatal HIV transmission and pregnancy complications. We aim to explore and explain the mechanism of effect of a family planning support intervention investigated in a randomized controlled trial conducted between October 2016 and June 2018 among 320 postpartum WLWH at a referral hospital in Southwestern Uganda that led to improved uptake, decreased contraception discontinuation and lowered pregnancy rates. Thirty WLWH and 10 of their primary sexual partners who participated in this trial were purposively selected and interviewed in the local language; interviews were digitally recorded. Translated transcripts were generated and coded. Coded data were iteratively reviewed and sorted to derive descriptive categories using an inductive content analytic approach. Up to 83% of women wanted to avoid pregnancy within the first year postpartum. Qualitative data showed that contraception uptake and use were influenced by: 1) Participant awareness and understanding of different methods available; 2) Participant perception of offered health services; 3) Healthcare provider (HCP) socio-cultural sensitivity to individual experiences and (mis)conceptions surrounding contraception; 4) Having tactile engagement, follow-up reminders and a reference to prompt action or discussions with partners. Supportive and culturally sensitive HCPs and systems facilitated information sharing leading to increased patient awareness and understanding of the contraceptive methods, and improved health user experience, care engagement, confidence and willingness to take up and continue using modern contraceptive methods.

Social capital and food security in post-conflict rural Lira District, northern Uganda

While a strong relationship has been established between social capital and food security in the research literature, it is uncertain whether this holds in post-conflict situations. This study examines associations between social capital and food security in post-conflict Lira District, northern Uganda. Since factors affecting food security are complex, we explored the roles of households' characteristics in food security outcomes. Data were collected from March to July 2011 through face-to-face interviews with 221 heads of household in rural Lira. Using multinomial logistic regression, a strong positive association was identified between social capital and household food security. The study also found significant associations of food security with sex, education of household head, amount of cultivated land, and farm and home possessions. The results of this analysis can aid the design of food security programmes that empower poor people while targeting the most vulnerable groups, thereby promoting sustainable development in post-conflict communities.

Understanding patterns of family support and its role on viral load suppression among youth living with HIV aged 15 to 24 years in southwestern Uganda

BACKGROUND

Active family support helps as a buffer against adverse life events associated with antiretroviral therapy (ART) uptake and adherence. There is limited data available to explain how family support shapes and affects individual healthcare choices, decisions, experiences, and health outcomes among youth living with HIV (YLWH). We aimed to describe family support patterns and its role in viral load suppression among YLWH at a rural hospital in southwestern Uganda.

METHODS

We performed a mixed-method cross-sectional study between March and September 2020, enrolling 88 eligible YLWH that received ART for at least 6 months. Our primary outcome of interest was viral load suppression, defined as a viral load detected of ≤500 copies/mL. Data analysis was performed using Statistical Package for Social Sciences version 20. Fifteen individuals were also purposively selected from the original sample and participated in an in-depth interview that was digitally recorded. Generated transcripts were coded and categories generated manually using the inductive content analytic approach. All participants provided written consent or guardian/parent assent (those <18 years) to participate in the study.

RESULTS

Forty-nine percent of YLWH were females, the median age was 21 (IQR: 16-22) years. About half of the participants (53%) stayed with a family member. A third (34%) of participants had not disclosed their status to any person they stayed with at home. Only 23% reported getting moderate to high family social support (Median score 2.3; IQR: 1.6-3.2). Seventy-eight percent of YLWH recorded viral load suppression. Viral load suppression was associated with one living with a parent, sibling, or spouse (AOR: 6.45; 95% CI: 1.16-16.13; P = .033), having a primary caretaker with a regular income (AOR: 1.57; 95% CI: 1.09-4.17; P = .014), and living or communicating with family at least twice a week (AOR: 4.2; 95% CI: 1.65-7.14; P = .003). Other significant factors included youth receiving moderate to high family support (AOR: 12.11; 95% CI: 2.06-17.09; P = .006) and those that perceived family support in the last 2 years as helpful (AOR: 1.98; 95% CI: 1.34-3.44; P = .001). HIV stigma (AOR: 0.10; 95% CI: 0.02-0.23; P = .007) and depression (AOR: 0.31; 95% CI: 0.06-0.52; P = .041) decreased viral load suppression. Qualitative data showed that dysfunctional family relationships, economic insecurity, physical separation, HIV- and disclosure-related stigma, past and ongoing family experiences with HIV/ART affected active family support. These factors fueled feelings of abandonment, helplessness, discrimination, and economic or emotional strife among YLWH.

CONCLUSION

Our data showed that living with a family member, having a primary caretaker with a regular income, living or communicating with family members regularly, and reporting good family support were associated with viral load suppression among YLWH in rural southwestern Uganda. Experiencing depression due to HIV and or disclosure-related stigma was associated with increased viral load. All YLWH desire ongoing emotional, physical, and financial support from immediate family to thrive and take medications daily and timely. Future interventions should explore contextual community approaches that encourage acceptance, disclosure, and resource mobilization for YLWH who rely on family support to use ART appropriately.

Normative vs personal attitudes toward persons with HIV, and the mediating role of perceived HIV stigma in rural Uganda

Background

HIV stigma has well-documented negative impacts on HIV testing, transmission risk behavior, initiation of and adherence to antiretroviral therapy, and retention in care. We sought to assess the extent to which anticipated HIV stigma is based on misperceptions of normative attitudes toward persons with HIV, and to determine whether persons with HIV have stronger misperceptions compared with HIV-negative persons or persons of unknown serostatus. We also sought to estimate the association between normative attitudes about persons with HIV and personal attitudes about persons with HIV, and to determine the extent to which anticipated stigma mediates this association.

Methods

We conducted a whole-population survey of 1776 persons living in 8 rural villages in southwestern Uganda. Negative attitudes toward persons with HIV, and anticipated stigma, were measured using a newly validated 15-item scale measuring multiple dimensions of HIV stigma, including social distance, blaming attitudes, and concerns about reciprocity. We used multivariable regression to estimate the association between normative attitudes about persons with HIV and personal attitudes toward persons with HIV, and to determine the extent to which perceptions of normative attitudes (anticipated stigma) mediated this association.

Results

Study participants believed that negative attitudes toward persons with HIV were more pervasive than they actually are. Perceptions of the extent to which these negative attitudes are normative mediated more than one-third of the association between normative attitudes and their personal attitudes. In contrast to what we originally hypothesized, persons with HIV were less likely to misperceive these norms and perceived normative attitudes to be less stigmatizing than did others in the general population.

Conclusions

Interventions designed to accurately describe normative attitudes toward persons with HIV may reduce HIV stigma without directly focusing on the educational components that are typically embedded in anti-stigma interventions.

Association between obesity and combination antiretroviral therapy (cART) adherence among persons with early-stage HIV infection initiating cART

BACKGROUND

Obesity is common among people living with HIV (PLWH) and early-stage infection, yet associations with combination antiretroviral (cART) adherence are unclear.

METHODS

Among PLWH initiating cART in Uganda and South Africa, body mass index (BMI) was assessed at cART initiation, and cART adherence was monitored in real-time over 12 months. The association of obesity (BMI ≥ 30 kg/m2) with adherence was assessed among nonpregnant participants with CD4 > 350 cells/mm3 using fractional regression modeling.

RESULTS

Among 322 participants, median age was 32 years, 70% were female, and 54% were from Uganda. Prevalence of obesity was 12% in Uganda and 28% in South Africa. Mean overall cART adherence was 83% in Uganda and 66% in South Africa. Participants with obesity had higher adherence than those without obesity: +3.6% (p = 0.44) in Uganda and +11.4% (p = 0.02) in South Africa.

CONCLUSION

Obesity at cART initiation was common and associated with higher adherence, although only significantly in South Africa.

Correlates of attendance at community engagement meetings held in advance of bio-behavioral research studies: A longitudinal, sociocentric social network study in rural Uganda

BACKGROUND

Community engagement is central to the conduct of health-related research studies as a way to determine priorities, inform study design and implementation, increase recruitment and retention, build relationships, and ensure that research meets the goals of the community. Community sensitization meetings, a form of community engagement, are often held prior to the initiation of research studies to provide information about upcoming study activities and resolve concerns in consultation with potential participants. This study estimated demographic, health, economic, and social network correlates of attendance at community sensitization meetings held in advance of a whole-population, combined behavioral, and biomedical research study in rural Uganda.

METHODS AND FINDINGS

Research assistants collected survey data from 1,630 adults participating in an ongoing sociocentric social network cohort study conducted in a rural region of southwestern Uganda. These community survey data, collected between 2016 and 2018, were linked to attendance logs from community sensitization meetings held in 2018 and 2019 before the subsequent community survey and community health fair. Of all participants, 264 (16%) attended a community sensitization meeting before the community survey, 464 (28%) attended a meeting before the community health fair, 558 (34%) attended a meeting before either study activity (survey or health fair), and 170 (10%) attended a meeting before both study activities (survey and health fair). Using multivariable Poisson regression models, we estimated correlates of attendance at community sensitization meetings. Attendance was more likely among study participants who were women (adjusted relative risk [ARR]health fair = 1.71, 95% confidence interval [CI], 1.32 to 2.21, p < 0.001), older age (ARRsurvey = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001; ARRhealth fair = 1.02 per year, 95% CI, 1.01 to 1.02, p < 0.001), married (ARRsurvey = 1.74, 95% CI, 1.29 to 2.35, p < 0.001; ARRhealth fair = 1.41, 95% CI, 1.13 to 1.76, p = 0.002), and members of more community groups (ARRsurvey = 1.26 per group, 95% CI, 1.10 to 1.44, p = 0.001; ARRhealth fair = 1.26 per group, 95% CI, 1.12 to 1.43, p < 0.001). Attendance was less likely among study participants who lived farther from meeting locations (ARRsurvey = 0.54 per kilometer, 95% CI, 0.30 to 0.97, p = 0.041; ARRhealth fair = 0.57 per kilometer, 95% CI, 0.38 to 0.86, p = 0.007). Leveraging the cohort's sociocentric design, social network analyses suggested that information conveyed during community sensitization meetings could reach a broader group of potential study participants through attendees' social network and household connections. Study limitations include lack of detailed data on reasons for attendance/nonattendance at community sensitization meetings; achieving a representative sample of community members was not an explicit aim of the study; and generalizability may not extend beyond this study setting.

CONCLUSIONS

In this longitudinal, sociocentric social network study conducted in rural Uganda, we observed that older age, female sex, being married, membership in more community groups, and geographical proximity to meeting locations were correlated with attendance at community sensitization meetings held in advance of bio-behavioral research activities. Information conveyed during meetings could have reached a broader portion of the population through attendees' social network and household connections. To ensure broader input and potentially increase participation in health-related research studies, the dissemination of research-related information through community sensitization meetings may need to target members of underrepresented groups.

Social Support, Food Insecurity, and HIV Stigma Among Men Living with HIV in Rural Southwestern Uganda: A Cross-Sectional Analysis

BACKGROUND

HIV stigma is one of the major barriers to HIV care due to the fear of disclosure and social discrimination. HIV stigma among men in sub-Saharan countries, including Uganda, has been linked to the fear about how HIV status might affect their status in society. HIV among men in sub-Saharan settings has been associated with feelings of shame, reduced self-worth, and self-blame for their HIV positive status. Information about HIV stigma and its associated factors among men living with HIV in rural Uganda is limited. This study assessed the burden of HIV stigma and its association with social support and food insecurity among men accessing HIV care at a rural health facility in southwestern Uganda.

METHODS

We conducted a clinic-based cross-sectional study and consecutively enrolled 252 adult men accessing HIV care at a rural health centre in southwestern Uganda. We collected information on sociodemographic information, HIV stigma, social support, and food insecurity. We fitted modified Poisson regression models to determine the associations between social support, food insecurity, and HIV stigma.

RESULTS

The mean HIV stigma score of the study participants was 70.08 (SD 19.34) and 75% reported food insecurity 5% of whom were severely food insecure. The risk of HIV stigma was lower among those aged 35 years and above (adjusted risk ratio [ARR]=0.89; 95% CI 0.83-0.96; P=0.003, those who had been on ART for more than 5 years (ARR=0.92; 95% CI=0.84-0.99; P=0.04), and those who had social support (ARR=0.99; 95% CI=0.98-0.99; P=<0.001). Food insecurity was associated with an increased risk of HIV stigma (ARR=1.07; 95% CI 1.00-1.15; P=0.03). Social support moderated the effect of food insecurity on HIV stigma (P=0.45).

CONCLUSION

Stigma is common among men living with HIV in rural Uganda and is significantly associated with food insecurity. Social support moderated the effect of severe food insecurity on HIV stigma among men living with HIV. Interventions to build social support systems and to economically empower men living with HIV should be incorporated into the mainstream HIV care clinics.

Structured and sustained family planning support facilitates effective use of postpartum contraception amongst women living with HIV in South Western Uganda: A randomized controlled trial

BACKGROUND

Despite low pregnancy intentions, many women accessing contraception discontinue use, increasing the risk of unwanted pregnancies among women living with HIV (WLWH). We evaluate whether a family planning support intervention, inclusive of structured immediate one-on-one postpartum counseling, and a follow-up mechanism through additional health information and SMS reminders affects continuous contraceptive use and pregnancy incidence among recently postpartum WLWH.

METHODS

We performed a randomized controlled trial between October 2016 and June 2018 at a referral hospital in southwestern Uganda. We included adult WLWH randomized and enrolled in a 1:1 ratio to receive family planning support or standard of care (control) and completed an interviewer-administered questionnaire at enrolment, 6 and 12 months postpartum. Our two primary outcomes of interest were; continuous use of contraception, and incidence of pregnancy. Secondary outcomes included contraception uptake, method change, discontinuation and pregnancy intentions. The trial was registered with clinicaltrials.gov (NCT02964169).

RESULTS

A total of 317(99%) completed all study procedures. Mean age was 29.6 (SD = 6.0) vs 30.0 (SD = 5.9) years for the intervention vs control groups respectively. All women were enrolled on ART. Total women using contraception continuously were 126 (79.8%) in the intervention compared to 110 (69.2%) in control group (odds ratio (OR) = 1.75; confidence interval (CI) = 1.24-2.75, P = 0.003). Pregnancy rates were 2% (N = 3) in the intervention vs 9% (N = 14) in the control group (OR = 0.20, 95% CI = 0.05-0.62, P = 0.006). Pregnancy intention was lower in the intervention vs control group (OR = 0.23, 95% CI = 0.08-0.64, P = 0.002). Women actively enrolled on contraception reduced more in the control compared to the intervention group (OR = 3.92, 95% CI = 1.66-9.77, P = 0.001). Women enrolled on each contraceptive method did not differ by group except for implants. More women initiating contraception use within three months postpartum had better continued use for either intervention (N = 123, 97.6% vs N = 3,2.4%) or control group (N = 86,78.2% vs N = 24,21.8%). Method-related side effects were less reported in the intervention group (OR = 0.25, 95% CI = 0.10-0.60, P = 0.001).

CONCLUSION

We found that sustained and structured family planning support facilitates continuous use of contraception and lowers rates of pregnancy amongst postpartum WLWH in rural southwestern Uganda. Women who initiated contraception within three months postpartum were more likely to maintain continuous use of contraception than those initiating later. Further evaluation of actual and perceived facilitators to the continuous contraception use by this support intervention will help replication in similar settings.

TRIAL REGISTRATION

NCT02964169.

Evaluating potential mediators for the impact of a family-based economic intervention (Suubi+Adherence) on the mental health of adolescents living with HIV in Uganda

INTRODUCTION

Many adolescents living with HIV in sub-Saharan Africa (SSA) experience poverty and have access to limited resources, which can impact HIV and mental health outcomes. Few studies have analyzed the impact of economic empowerment interventions on the psychosocial wellbeing of adolescents living with HIV in low resource communities, and this study aims to examine the mediating mechanism(s) that may explain the relationship between a family economic empowerment intervention (Suubi + Adherence) and mental health outcomes for adolescents (ages 10-16 at enrollment) living with HIV in Uganda.

METHOD

We utilized data from Suubi + Adherence, a large-scale six-year (2012-2018) longitudinal randomized controlled trial (N = 702). Generalized structural equation models (GSEMs) were conducted to examine 6 potential mediators (HIV viral suppression, food security, family assets, and employment, HIV stigma, HIV status disclosure comfort level, and family cohesion) to determine those that may have driven the effects of the Suubi + Adherence intervention on adolescents' mental health.

RESULTS

Family assets and employment were the only statistically significant mediators during follow-up (β from -0.03 to -0.06), indicating that the intervention improved family assets and employment which, in turn, was associated with improved mental health. The proportion of the total effect mediated by family assets and employment was from 42.26% to 71.94%.

CONCLUSIONS

Given that mental health services provision is inadequate in SSA, effective interventions incorporating components related to family assets, employment, and financial stability are crucial to supporting the mental health needs of adolescents living with HIV in under-resourced countries like Uganda. Future research should work to develop the sustainability of such interventions to improve long-term mental health outcomes among this at-risk group.

Adverse childhood experiences, adult depression, and suicidal ideation in rural Uganda: A cross-sectional, population-based study

BACKGROUND

Depression is recognized globally as a leading cause of disability. Early-life adverse childhood experiences (ACEs) have been shown to have robust associations with poor mental health during adulthood. These effects may be cumulative, whereby a greater number of ACEs are progressively associated with worse outcomes. This study aimed to estimate the associations between ACEs and adult depression and suicidal ideation in a cross-sectional, population-based study of adults in Uganda.

METHODS AND FINDINGS

Between 2016 and 2018, research assistants visited the homes of 1,626 adult residents of Nyakabare Parish, a rural area in southwestern Uganda. ACEs were assessed using a modified version of the Adverse Childhood Experiences-International Questionnaire, and depression symptom severity and suicidal ideation were assessed using the Hopkins Symptom Checklist for Depression (HSCL-D). We applied a validated algorithm to determine major depressive disorder diagnoses. Overall, 1,458 participants (90%) had experienced at least one ACE, 159 participants (10%) met criteria for major depressive disorder, and 28 participants (1.7%) reported suicidal ideation. We fitted regression models to estimate the associations between cumulative number of ACEs and depression symptom severity (linear regression model) and major depressive disorder and suicidal ideation (Poisson regression models). In multivariable regression models adjusted for age, sex, primary school completion, marital status, self-reported HIV status, and household asset wealth, the cumulative number of ACEs was associated with greater depression symptom severity (b = 0.050; 95% confidence interval [CI], 0.039-0.061, p < 0.001) and increased risk for major depressive disorder (adjusted relative risk [ARR] = 1.190; 95% CI, 1.109-1.276; p < 0.001) and suicidal ideation (ARR = 1.146; 95% CI, 1.001-1.311; p = 0.048). We assessed the robustness of our findings by probing for nonlinearities and conducting analyses stratified by age. The limitations of the study include the reliance on retrospective self-report as well as the focus on ACEs that occurred within the household.

CONCLUSIONS

In this whole-population, cross-sectional study of adults in rural Uganda, the cumulative number of ACEs had statistically significant associations with depression symptom severity, major depressive disorder, and suicidal ideation. These findings highlight the importance of developing and implementing policies and programs that safeguard children, promote mental health, and prevent trajectories toward psychosocial disability.

Delay discounting and obesity in food insecure and food secure women

OBJECTIVES

The relation between food insecurity (FI) and delay discounting (DD) and probability discounting (PD) for food and money was tested in women. In addition, discounting was tested as a variable that mediates the relation between obesity and FI.

METHOD

Women recruited from a community sample (N = 92) completed questionnaires. They completed the food choice questionnaire, the monetary choice questionnaire, measures for food and money probability discounting (which quantify sensitivity to risk aversion), and demographic measures.

RESULTS

Women with FI had higher rates of obesity and higher food DD compared to food-secure women. However, DD for money or probability discounting for food or money did not significantly differ between FI and food secure groups when controlling for significant covariates. Neither DD or PD significantly mediated the relation between FI and obesity.

CONCLUSIONS

These results suggest that FI is associated with greater impulsive food choice, but its association with other monetary discounting and probability discounting for food and money appears contingent upon other demographic factors. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

High magnitude of food insecurity and malnutrition among people living with HIV/AIDS in Ethiopia: A call for integration of food and nutrition security with HIV treatment and care Programme

BACKGROUND

Food insecurity and malnutrition has been reported to have a strong connection with human immunodeficiency viruses (HIV); this is more pervasive in Sub-Saharan Africa including Ethiopia. In this study, we examined the predictors of food insecurity and factors associated with malnutrition among people living with HIV (PLHIV) in Benishangul Gumuz Regional State, Ethiopia.

METHODS

We conducted a cross-sectional study at outpatient antiretroviral therapy (ART) clinics. Data were collected using participant interview, anthropometry, and participants' chart review. Interviews were carried out with 390 PLHIVs who were on antiretroviral treatment follow-up. Four robust multivariate linear regression models were used to identify predictors of food insecurity and factors associated with malnutrition.

RESULTS

The prevalence of food insecurity and malnutrition among PLHIV were found to be 76% and 60%, respectively. The predictors of food insecurity were: urban residence; household dependency; average monthly income below 53.19 USD; poor asset possession; CD4 count below 350 cell/μL; and recurrent episodes of opportunistic infections (OIs). Correspondingly, malnutrition among PLHIV was found strongly associated with: female gender; urban residence; income below 53.19 USD; poor asset possession; duration of less than one year on ART; and recurrent episodes of OIs.

CONCLUSION

The study findings suggest that the higher prevalence of food insecurity and malnutrition among PLHIV underscore: the need for economic and livelihood intervention; addressing contextual factors including the gender dimensions; adoption of nutrition-specific and sensitive interventions; and integration of food and nutrition security with HIV treatment and care programmes.

Adherence to HIV antiretroviral therapy among pregnant and postpartum women during the Option B+ era: 12-month cohort study in urban South Africa and rural Uganda

INTRODUCTION

We conducted a cohort study to understand patterns of anti-retroviral therapy (ART) adherence during pregnancy, postpartum and non-pregnancy follow-up among women initiating ART in public clinics offering Option B+ in rural Uganda and urban South Africa.

METHODS

We collected survey data, continuously monitored ART adherence (Wisepill), HIV-RNA and pregnancy tests at zero, six and twelve months from women initiating ART in Uganda and South Africa, 2015 to 2017. The primary predictor of interest was follow-up time categorized as pregnant (pregnancy diagnosis to pregnancy end), postpartum (pregnancy end to study exit) or non-pregnancy-related (neither pregnant nor postpartum). Fractional regression models included demographics and socio-behavioural factors informed by the Behavioral Model for Vulnerable Populations. We evaluated HIV-RNA at 12 months by ever- versus never-pregnant status.

RESULTS

In Uganda, 247 women contributed 676, 900 and 1274 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median ART adherence was consistently ≥90%: pregnancy, 94% (interquartile range [IQR] 78,98); postpartum, 90% (IQR 70,97) and non-pregnancy, 90% (IQR 80,98). Poorer adherence was associated with younger age (0.98% [95% CI 0.33%, 1.62%] average increase per year of age) and higher CD4 cell count (1.01% [0.08%, 1.94%] average decrease per 50 cells/mm3 ). HIV-RNA was suppressed among 91% (N = 135) ever-pregnant and 86% (N = 85) never-pregnant women. In South Africa, 190 women contributed 259, 624 and 1247 months of pregnancy, postpartum and non-pregnancy-related follow-up. Median adherence was low during pregnancy, 74% (IQR 31,96); postpartum, 40% (IQR 4,65) and non-pregnancy, 77% (IQR 47,92). Poorer adherence was associated with postpartum status (22.3% [95%CI 8.6%, 35.4%] average decrease compared to non-pregnancy-related follow-up) and less emotional support (1.4% [0.22%, 2.58%] average increase per unit increase). HIV-RNA was suppressed among 57% (N = 47) ever-pregnant and 86% (N = 93) never-pregnant women.

CONCLUSIONS

Women in rural Uganda maintained high adherence with 91% of ever-pregnant and 86% of never-pregnant women suppressing HIV-RNA at 12 months. Women in urban South Africa struggled with adherence, particularly during postpartum follow-up with median adherence of 40% and 57% of women with HIV-RNA suppression at one year, suggesting a crisis for postpartum women with HIV in South Africa. Findings suggest that effective interventions should promote emotional support.

Food Insecurity among People Living with HIV/AIDS on ART Follower at Public Hospitals of Western Ethiopia

Background

Food insecurity and HIV/AIDS are intertwined in a vicious cycle through nutritional, mental health, and behavioral pathways. Food insecurity is a potentially important barrier to the success of antiretroviral treatment, increased hospitalizations, and higher morbidity among HIV-infected individuals in resource-poor settings particularly in sub-Saharan Africa including Ethiopia. Therefore, the purpose of this study was to assess the prevalence of food insecurity among people living with HIV/AIDS on follow up at public hospitals of western Ethiopia.

Methods

An institutional-based cross-sectional study design was conducted on a sample of 428 among people living with HIV/AIDS on follow up at public hospitals of western Ethiopia. A systematic random sampling technique was used to include all participants. Data was collected using interviewer-administered structured questionnaires. The data were entered into Epi data version 3.1 and then exported into Statistical Package for the Social Sciences window version 21 for analysis. Descriptive and inferential statistics were employed. Bivariable logistic and multivariable logistic analyses were used with AOR at CI 95% and p < 0.05 were used.

Result

The finding of the study revealed that the majority of the respondents 221(53.1%) were female. The mean age of the respondents was 32.92 ± 7.304 years and 197 (47.4%) of the study participants were between 30 to 39 years' age group. The level of food insecurity among PLWHA receiving ART therapy was 68.8% which was partitioned as mild (23.32%), moderate (29.09%), and severe (16.35%) food in secured. Being single [AOR = 3.507(1.377, 8.934)], illiterate [AOR = 5.234(1.747, 15.686)], cigarette smoking [AOR = 3.577(2.104, 6.081)], presence of anemia (AOR = 2.650(1.563, 4.493)], and inadequate dietary diversity [AOR = 2.870(1.088, 7.569)] were predictors of food insecurity.

Conclusion

The prevalence of food insecurity was high. Educational status, marital status, cigarette smoking, presence of anemia, opportunistic infection, and inadequate dietary diversity were the major significant factors affecting food insecurity. We recommended a national health policy maker to integrate food and nutrition interventions as part of a package of care, treatment, and support services for people living with HIV and ART follower patients.

Gender, HIV-Related Stigma, and Health-Related Quality of Life Among Adults Enrolling in HIV Care in Tanzania

HIV-related stigma has been associated with worse health-related quality of life (HRQoL) among people living with HIV (PLWH). Little is known about how different types of HIV-related stigma (i.e., anticipatory, internalized, or enacted HIV-related stigma) influence HRQoL and whether these relationships differ by gender. The sample included 912 PLWH aged 18 years or older enrolling in HIV care at four health facilities in Tanzania. HRQoL was assessed with the life satisfaction and overall function subscales of the HIV/AIDS-Targeted Quality of Life (HAT-QoL) instrument. Sex-stratified multivariable logistic regression modeled the association of anticipatory, internalized, and enacted HIV-related stigma on poor HRQoL. Across all participants, the mean life satisfaction score was 63.4 (IQR: 43.8, 81.3) and the mean overall function score was 72.0 (IQR: 58.3, 91.7). Mean HRQoL scores were significantly higher for women compared to men for overall function (5.1 points higher) and life satisfaction (4.3 points higher). Fourteen percent of respondents reported recent enacted HIV-related stigma and 13% reported recent medium or high levels of internalized stigma. In multivariable models, high internalized and high anticipatory stigma were significantly associated with higher odds of poor life satisfaction and poor overall function in both men and women. Psychosocial interventions to prevent or reduce the impact of internalized and anticipatory stigma may improve HRQoL among persons in HIV care. Future research should longitudinally examine mechanisms between HIV-related stigma, poor HRQoL, and HIV care outcomes.

"When you have no water, it means you have no peace": A mixed-methods, whole-population study of water insecurity and depression in rural Uganda

BACKGROUND

Lack of access to clean water has well known implications for communicable disease risks, but the broader construct of water insecurity is little studied, and its mental health impacts are even less well understood.

METHODS AND FINDINGS

We conducted a mixed-methods, whole-population study in rural Uganda to estimate the association between water insecurity and depression symptom severity, and to identify the mechanisms underlying the observed association. The whole-population sample included 1776 adults (response rate, 91.5%). Depression symptom severity was measured using a modified 15-item Hopkins Symptom Checklist for Depression. Water insecurity was measured with a locally validated 8-item Household Water Insecurity Access Scale. We fitted multivariable linear and Poisson regression models to the data to estimate the association between water insecurity and depression symptom severity, adjusting for age, marital status, self-reported overall health, household asset wealth, and educational attainment. These models showed that water insecurity was associated with depression symptom severity (b = 0.009; 95% confidence interval [CI], 0.004-0.15) and that the estimated association was larger among men (b = 0.012; 95% CI, 0.008-0.015) than among women (b = 0.008; 95% CI, 0.004-0.012. We conducted qualitative interviews with a sub-group of 30 participants, focusing on women given their traditional role in household water procurement in the Ugandan context. Qualitative analysis, following an inductive approach, showed that water insecurity led to "choice-less-ness" and undesirable social outcomes, which in turn led to emotional distress. These pathways were amplified by gender-unequal norms.

CONCLUSIONS

Among men and women in rural Uganda, the association between water insecurity and depression symptom severity is statistically significant, substantive in magnitude, and robust to potential confounding. Data from the qualitative interviews provide key narratives that reveal the mechanisms through which women's lived experiences with water insecurity may lead to emotional distress.

Alcohol, But Not Depression or IPV, Reduces HIV Adherence Among South African Mothers Living with HIV Over 5 Years

Alcohol, depression, and intimate partner violence (IPV) are endemic in sub-Saharan Africa. This article examines whether and how these conditions affect mothers living with HIV (MLH), compared to mothers without HIV (MWOH). In particular, we assess the influence of these comorbidities on engagement in HIV care and adherence to antiretroviral therapies (ARV) among MLH. Data on maternal HIV care are typically based on clinic samples, with substantial loss to follow-up. This study fills that gap by including all mothers in specified areas. A cohort study examines MLH in Cape Town, South Africa recruited in pregnancy and followed repeatedly for 5 years, compared to MWOH. Almost all (98%) pregnant women in 12 neighborhoods (N = 594) were recruited in pregnancy. Mothers and children were reassessed five times over 5 years with high retention rates at each of the six assessments, from 98.7% at 2 weeks to 82.8% at 5 years post-birth. MLH's uptake and adherence to HIV care was evaluated over time associated with maternal comorbidities of alcohol use, depressed mood, and IPV using mixed effects logistic regression. MLH have fewer resources (income, food, education) and are more likely to face challenges from alcohol, depression, and having seropositive partners over time than MWOH. Only 22.6% of MLH were consistently engaged in HIV care from 6 months to 5 years post-birth. At 5 years, 86.7% self-reported engaged in HIV care, 76.9% were receiving ARVs and 87% of those on ARV reported consistent ARV adherence. However, data on viral suppression are unavailable. Alcohol use, but not depressed mood or IPV, was significantly related to reduced uptake of HIV care and adherence to ARV over time. Adherence to lifelong ARV by MLH requires a combination of structural and behaviorally-focused interventions. Alcohol abuse is not typically addressed in low and middle-income countries, but is critical to support MLH.

Psychosocial Factors Associated with Food Insufficiency Among People Living with HIV/AIDS (PLWH) Initiating ART in Ethiopia

Food insufficiency is associated with suboptimal HIV treatment outcomes. Less is known about psychosocial correlates of food insufficiency among PLWH. This sample includes 1176 adults initiating antiretroviral therapy at HIV clinics in Ethiopia. Logistic regression modeled the association of psychological distress, social support, and HIV-related stigma with food insufficiency. Among respondents, 21.4% reported frequent food insufficiency. Psychological distress [adjusted odds ratio (aOR) 2.61 (95% CI 1.79, 3.82)], low social support [aOR 2.20 (95% CI 1.57, 3.09)] and enacted stigma [aOR 1.69 (95% CI 1.26, 2.25)] were independently associated with food insufficiency. Food insufficiency interventions should address its accompanying psychosocial context.

Severe Food Insecurity, Gender-Based Violence, Homelessness, and HIV Risk among Street-based Female Sex Workers in Baltimore, Maryland

Despite established links between food insecurity and HIV outcomes, no studies have examined the role of food insecurity among female sex workers (FSW) in the United States (US). The aim of this exploratory study was to identify correlates (structural vulnerability and health factors) of severe food insecurity among street-based FSW in Baltimore, Maryland using multivariable logistic regression. In adjusted models, FSW with severe food insecurity were at greater odds of recent homelessness, physical intimate partner violence, client condom refusal, and HIV infection. Multi-sectoral approaches must take into consideration the co-occurrence of structural and health vulnerabilities to food insecurity among FSW in the US, including those that address violence, housing, and HIV.

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

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

Association of Gut Intestinal Integrity and Inflammation with Insulin Resistance in Adults Living with HIV in Uganda

We conducted a cross-sectional study of 148 HIV+ on HIV antiretroviral therapy and 149 HIV- adults in Mbarara, Uganda, to estimate the association between HIV infection and homeostasis model assessment of insulin resistance (HOMA-IR) using multivariable regression analysis. In addition, we evaluated whether intestinal fatty acid-binding protein (I-FABP), monocyte activation markers soluble (s)CD14 and sCD163, and proinflammatory cytokine interleukin 6 (IL-6) mediated this association. HOMA-IR was greater among HIV+ than HIV- adults [median (interquartile range): 1.3 (0.7-2.5) vs. 0.9 (0.5-2.4); p = 0.008]. In models adjusted for sociodemographic variables, diet, hypertension, and smoking history, HIV infection was associated with 37% [95% confidence intervals (95% CIs): 5-77] greater HOMA-IR compared with HIV- participants. The magnitude of association was greater when I-FABP was included as a covariate although the additive effect was modest (40% CI: 8-82). By contrast adding sCD14 to the model was associated with greater HOMA-IR (59%; 95% CI: 21-109) among HIV+ participants compared with HIV- participants. Among HIV+ participants, greater CD4 nadir was non-significantly associated with greater HOMA-IR (22%; 95% CI: -2 to 52). Each 5-unit increase in body mass index (BMI; 49% greater HOMA-IR; 95% CI: 18-87) and female sex (71%; 95% CI: 17-150) remained associated in adjusted models. In this study of mainly normal-weight Ugandan adults, HIV infection, female sex, and greater BMI were all associated with greater insulin resistance (IR). This association was strengthened modestly after adjustment for sCD14, suggesting possible distinct immune pathways to IR that are independent of HIV or related to inflammatory changes occurring on HIV treatment.

Evaluation of a social network intervention on child feeding practices and caregiver knowledge

Food insecurity and poor infant and young child feeding (IYCF) practices contribute to undernutrition. The Kanyakla Nutrition Program was developed in rural Kenya to provide knowledge alongside social support for recommended IYCF practices. Utilizing a social network approach, the Kanyakla Nutrition Program trained community health workers (CHWs) to engage mothers, fathers, and grandparents in nutrition education and discussions about strategies to provide instrumental, emotional, and information support within their community. The 12-week programme included six sessions and was implemented on Mfangano Island, Kenya, in 2014-2015. We analysed intervention effects on (a) nutrition knowledge among community members or CHWs and (2) IYCF practices among children 1-3 years. Nutrition knowledge was assessed using a postintervention comparison among intervention (community, n = 43; CHW, n = 22) and comparison groups (community, n = 149; CHW, n = 64). We used a quasi-experimental design and difference-in-difference to assess IYCF indicators using dietary recall data from an ongoing cohort study among intervention participants (n = 48) with individuals living on Mfangano Island where the intervention was not implemented (n = 178) before the intervention, within 1 month postintervention, and 6 months postintervention. Findings showed no effect of the intervention on IYCF indicators (e.g., dietary diversity and meal frequency), and less than 15% of children met minimum acceptable diet criteria at any time point. However, knowledge and confidence among community members and CHWs were significantly higher 2 years postintervention. Thus, a social network approach had an enduring effect on nutrition knowledge, but no effects on improved IYCF practices.

Factors Associated with Pregnancy Intentions Amongst Postpartum Women Living with HIV in Rural Southwestern Uganda

Comprehensive HIV treatment and care makes it safer for women living with HIV (WLWH) to have the children they desire, partly through provision and appropriate use of effective contraception. However, nearly one third of WLWH in-care in a large Ugandan cohort became pregnant within 3 years of initiating ART and half of these incident pregnancies (45%) were unplanned. We therefore describe future pregnancy plans and associated factors among postpartum WLWH in rural southwestern Uganda in order to inform interventions promoting postpartum contraceptive uptake. This analysis includes baseline data collected from adult WLWH enrolled into a randomized controlled trial to evaluate the effect of family planning support versus standard of care at 12 months postpartum in southwestern Uganda. Enrolled postpartum WLWH completed an interviewer-administered questionnaire at enrolment. Among 320 enrolled women, mean age, CD4 count, and duration on ART was 28.9 (standard deviation [SD] 5.8) years, 395 cells/mm³ (SD = 62) and 4.6 years (SD = 3.9), respectively. One-hundred and eighty nine (59%) of women reported either personal (175, 55%) or partner (186, 58%) desire for more children in the next 2 years. Intentions to have more children was strongly associated with partner’s desire for more children (AOR = 31.36; P < 0.000), referent pregnancy planned (AOR = 2.69; P = 0.050) and higher household income > 150,000 Shs per month (AOR = 1.37; P = 0.010). Previous use of modern contraception (AOR = 0.07; P = 0.001), increasing age (AOR = 0.34; P = 0.012), having > 2 own children living in a household (AOR = 0.42; P = 0.021) and parity > 2 (AOR = 0.59; P = 0.015) were associated with reduced odds of pregnancy intention. Our findings highlight the role male partners play in influencing pregnancy intentions postpartum and the importance of engaging men in sexual and reproductive health counselling about child spacing for the health of women, children, and families. This should be addressed alongside key individual-level social, demographic, economic and structural factors within which couples can understand risks of unplanned pregnancies and access effective contraceptive methods when they need or want them.