Modality of Primary HIV Disclosure and Association with Mental Health, Stigma, and Antiretroviral Therapy Adherence in Tanzanian Youth Living with HIV

Study protocol for Sauti ya Vijana (The Voice of Youth): A hybrid-type 1 randomized trial to evaluate effectiveness and implementation of a mental health and life skills intervention to improve health outcomes for Tanzanian youth living with HIV

OBJECTIVE

Young people living with HIV (YPLWH) experience increased morbidity and mortality compared to all other age groups. Adolescence brings unique challenges related to sexual reproductive health, the elevated importance of peer groups, and often, emerging symptoms of emotional distress. Failure to address this unique life stage for YPLWH can lead to worse HIV and mental health outcomes. Herein lies the protocol for a hybrid-type-1 effectiveness-implementation trial designed to evaluate a mental health and life skills intervention that aims to address these needs for YPLWH in Tanzania.

METHODS

This is an individually randomized group-treatment trial designed to evaluate the effectiveness of Sauti ya Vijana (SYV: The Voice of Youth) toward improving viral suppression (HIV RNA <400 copies/mL) and mental health outcomes and to assess implementation including acceptability, feasibility, fidelity, and cost-effectiveness of the manualized intervention. The trial is being conducted across four geographically distinct regions of Tanzania. Peer group leaders (PGL) with lived HIV experience deliver the 10-session group-based intervention and two individual sessions during which participants describe their disclosure narrative (when they learned they live with HIV) and value-based goal setting. Caregiver or chosen supportive adults are encouraged to attend two specific group sessions with their youth. Participants are 10-24 years of age, prescribed antiretroviral therapy for at least 6 months, fully aware of their HIV status, able to commit to session attendance, and able to understand and meaningfully contribute to group sessions. Participant study visits occur at 5 time points for evaluation: baseline, 4-, 6-, 12-, and 18-months post baseline. A single booster session is conducted before the 12-month visit. Study visits evaluate mental health, adverse childhood events, interpersonal violence, resilience, stigma, HIV knowledge, substance use, sexual relationships, ART adherence, and HIV RNA. Implementation outcomes evaluate feasibility and acceptability through attendance, intervention session notes, focus discussion groups and qualitative interviews. Fidelity to the intervention is measured using fidelity checklists by a PGL observer at each group session. Cost effectiveness is calculated using an incremental cost-effectiveness ratio that utilizes a patient cost questionnaire and financial records of study costs.

SIGNIFICANCE

Few mental health interventions for YPLWH have demonstrated effectiveness. Results from this study will provide information about effectiveness and implementation of a peer-led intervention for delivering a mental health and life skills intervention in low-income settings.

TRIAL IDENTIFIER

This trial is registered at clinicaltrials.gov NCT05374109.

Prevalence of mental disorders among young people living with HIV: a systematic review and meta-analysis

Objective

This meta-analysis aims to evaluate the global prevalence of mental disorders among young people living with HIV.

Methods

A comprehensive search was conducted of the PubMed, Embase, and Cochrane Library databases for articles relevant to the study, published between January 2013 and June 2023. To identify sources of heterogeneity and compare prevalence estimates among various groups, subgroup analyses were conducted. Study heterogeneity was assessed using Cochran's Q and the I 2 tests. The robustness of the findings was ascertained through sensitivity analyses, while publication bias was evaluated with funnel plots and Egger's test.

Results

Sixty studies were included in this meta-analysis. It revealed that approximately one-quarter of YLWH experience depression, with a prevalence of 24.6% (95% CI: 21.1-28.2%). The prevalence of anxiety was found to be 17.0% (95% CI: 11.4-22.6%). Regarding suicidality, the prevalence of suicidal ideation and lifetime suicidal ideation in YLWH was 16.8% (95% CI: 11.3-22.4%) and 29.7% (95% CI: 23.7-35.7%), respectively. Additionally, the prevalence rates for suicidal attempts and lifetime suicidal attempts were 9.7% (95% CI: 4.0-15.4%) and 12.9% (95% CI: 2.8-23.1%), respectively. The prevalence of Post-Traumatic Stress Disorder and Attention Deficit Hyperactivity Disorder was identified as 10.5% (95% CI: 5.8-15.2%) and 5.0% (95% CI: 3.1-7.0%), respectively.

Conclusion

The findings indicate a heightened risk of mental disorders among YLWH, underscoring the necessity for targeted intervention strategies to mitigate their suffering and potentially diminish the adverse impacts.

Systematic Review Registration

PROSPERO, identifier CRD42023470050, https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023470050.

Trajectories of adolescents living with vertical transmission-HIV virus

This study analyzes the life stories of eight young people living with vertically transmitted HIV in order to understand their perceptions marked by secrecy and silence regarding their experiences with the virus. Conducted at a specialized outpatient clinic in Rio de Janeiro, the study adopted circle dance, a Complementary and Integrative Health Practice, as a care tool. Using a qualitative approach and Life History as a data collection method, the focus was to understand the youth's experiences related to the disease and the crucial aspects of their lives. Three girls and five boys participated in the study, all aware of their diagnosis. The principal emerging themes included family dynamics, school environment connection, challenges in treatment adherence, age at the time of diagnosis disclosure, and time elapsed since then. Analyzing these young people's narratives allowed us to explore individual and social aspects of their experiences, revealing their similarities and differences. The circle dance workshops provided a playful space for expressing emotions and feelings through body movements, expanding young people's perspectives on the future.

The importance of self-management for better treatment outcomes for HIV patients in a low-income setting: perspectives of HIV experts and service providers

BACKGROUND

Self-management is the most important strategy to improve quality of life in patients with a chronic disease. Despite the increasing number of people living with HIV (PLWH) in low-income countries, very little research on self-management is conducted in this setting. The aim of this research is to understand the perspectives of service providers and experts on the importance of self-management for PLWH.

METHODS

A systematizing expert interview type of qualitative methodology was used to gain the perspectives of experts and service providers. The study participants had experience in researching, managing, or providing HIV service in east and southern African (ESA) countries. All the interviews were audio recorded, transcribed, and translated to English. The quality of the transcripts was ensured by randomly checking the texts against the audio record. A thematic analysis approach supported by Atlas TI version 9 software.

RESULT

PLWH face a variety of multi-dimensional problems thematized under contextual and process dimensions. The problems identified under the contextual dimension include disease-specific, facility-related, and social environment-related. Problems with individual origin, such as ignorance, outweighing beliefs over scientific issues, low self-esteem, and a lack of social support, were mostly highlighted under the process dimensions. Those problems have a deleterious impact on self-management, treatment outcomes, and the quality of life of PLWH. Low self-management is also a result of professional-centered service delivery in healthcare facilities and health service providers' incapacity to comprehend a patient's need beyond the medical concerns. Participants in the study asserted that patients have a significant stake in enhancing treatment results and quality of life through enhancing self-management.

CONCLUSION AND RECOMMENDATION

HIV patients face multifaceted problems beyond their medical issues. The success of medical treatment for HIV is strongly contingent upon patients' self-management practices and the supportive roles of their family, society, and health service providers. The development and integration of self-management practices into clinical care will benefit patients, their families, and the health system.

Disclosure of HIV status and associated clinical outcomes of children and adolescents living with HIV in Asia

Disclosure of HIV status is an important part of pediatric care. We studied disclosure and clinical outcomes in a multi-country Asian cohort of children and adolescents with HIV. Those 6-19 years of age who initiated combination antiretroviral therapy (cART) between 2008 and 2018, and who had at least one follow-up clinic visit were included. Data up to December 2019 were analyzed. Cox and competing risk regression analyses were used to assess the effect of disclosure on disease progression (WHO clinical stage 3 or 4), loss to follow-up (LTFU; > 12 months), and death. Of 1913 children and adolescents (48% female; median [IQR] age 11.5 [9.2-14.7] years at last clinic visit), 795 (42%) were disclosed to about their HIV status at a median age of 12.9 years (IQR: 11.8-14.1). During follow-up, 207 (11%) experienced disease progression, 75 (3.9%) were LTFU, and 59 (3.1%) died. There were lower hazards of disease progression (adjusted hazard ratio [aHR] 0.43 [0.28-0.66]) and death (aHR 0.36 [0.17-0.79]) for those disclosed to compared with those who were not. Disclosure and its appropriate implementation should be promoted in pediatric HIV clinics in resource-limited settings.

Management of depression in people living with HIV/AIDS in Senegal: Acceptability, feasibility and benefits of group interpersonal therapy

Depression is highly prevalent in people living with HIV (PLWH) and has negative consequences for daily life and care. We evaluated for the first time the acceptability, feasibility and benefits of group interpersonal therapy (IPT), combined with a task-shifting approach, to treat depression in PLWH in Senegal. PLWH with depression received group IPT following the World Health Organization protocol. Acceptability and feasibility criteria were defined from the literature data. The PHQ-9, the WHODAS, and the 12-item-stigma scale were used, pre- and post-treatment, including a 3-month follow-up, to assess depressive symptom severity, functioning and stigma, respectively. General linear mixed models were used to describe changes in outcomes over time. Of 69 participants, 60 completed group IPT. Refusal to enroll and dropout rates were 6.6 and 12.7%, respectively. Ninety-seven percent of participants attended at least seven out of eight sessions. Patients and facilitators endorsed group IPT, with willingness to recommend it. Depressive symptoms and disability improved drastically and sustainably. We showed that group IPT is well accepted and feasible in Senegal as treatment for depression in PLWH. Combined with a task-shifting approach, it can narrow the gap in mental health treatment. Implementation may be enhanced by refining patient identification procedures and increasing treatment accessibility.

Integrating Adolescent Mental Health into HIV Prevention and Treatment Programs: Can Implementation Science Pave the Path Forward?

Adolescent mental health (AMH) is a critical driver of HIV outcomes, but is often overlooked in HIV research and programming. The implementation science Exploration, Preparation, Implementation, Sustainment (EPIS) framework informed development of a questionnaire that was sent to a global alliance of adolescent HIV researchers, providers, and implementors working in sub-Saharan Africa with the aim to (1) describe current AMH outcomes incorporated into HIV research within the alliance; (2) identify determinants (barriers/gaps) of integrating AMH into HIV research and care; and (3) describe current AMH screening and referral systems in adolescent HIV programs in sub-Saharan Africa. Respondents reported on fourteen named studies that included AMH outcomes in HIV research. Barriers to AMH integration in HIV research and care programs were explored with suggested implementation science strategies to achieve the goal of integrated and sustained mental health services within adolescent HIV programs.

Effect of a customized digital adherence tool on retention in care and adherence to antiretroviral treatment in breastfeeding women, children and adolescents living with HIV in Tanzania: a mixed-methods study followed by clinical trials

BACKGROUND

Adherence to antiretroviral (ARV) treatment for HIV infection is challenging because of many factors. The World Health Organization (WHO) has recommended using digital adherence technologies (DATs). However, there is limited evidence on how DATs improve adherence. Wisepill® is an internet-enabled medication dispenser found feasible and acceptable in several studies. However, limited evidence is available on its effectiveness in improving ART adherence, specifically among children and adolescents. Furthermore, DATs are often developed without involving the target groups. We propose a two-stage project consisting of a formative study to customize an existing Wisepill DAT intervention and a randomized clinical trial to investigate the effectiveness of DAT combined with reminder cues and tailored feedback on adherence to ARV treatment among children and adolescents living with HIV and retention in care among breastfeeding women living with HIV in Kilimanjaro and Arusha Region, Tanzania.

METHODS

We will conduct a formative mixed-methods study and three sub-trials in Kilimanjaro and Arusha Regions among (1) children aged 0-14 years and their caregivers, (2) adolescents aged 15-19 years and (3) breastfeeding women and their HIV-negative infants. In the formative study, we will collect and analyse data on needs and contents for DATs, including the contents of short message service (SMS) texts and tailored feedback. The results will inform the customization of the DAT to be tested in the sub-trials. In the trials, participants will be randomized in the intervention arm, where the DAT will be implemented or the control arm, where standard care will be followed. Participants in the intervention arm will take their medication from the Wisepill box and receive daily reminder texts and tailored feedback during clinic visits.

DISCUSSION

If the intervention improves adherence to ART and the devices are acceptable, accurate and sustainable, the intervention can be scaled up within the National Aids Control Programmes.

TRIAL REGISTRATION

PACTR202301844164954, date 27 January 2023.

Stigma-directed services (Stig2Health) to improve 'linkage to care' for people living with HIV in rural Tanzania: study protocol for a nested pre-post implementation study within the Kilombero and Ulanga Antiretroviral Cohort

Background: HIV-related stigma is a major barrier to the timely linkage and retention of patients in HIV care in sub-Saharan Africa, where most people living with HIV/AIDS reside. In this implementation study we aim to evaluate the effect of stigma-directed services on linkage to care and other health outcomes in newly diagnosed HIV-positive patients. Methods: In a nested project of the Kilombero and Ulanga Antiretroviral Cohort in rural Tanzania, we conduct a prospective observational pre-post study to assess the impact of a bundle of stigma-directed services for newly diagnosed HIV positive patients. Stigma-directed services, delivered by a lay person living with HIV, are i) post-test counseling, ii) post-test video-assisted teaching, iii) group support therapy and group health education, and iv) mobile health. Patients receiving stigma services (enrolled from 1 st February 2020 to 31 st August 2021) are compared to a historical control receiving the standard of care (enrolled from 1 st July 2017 to 1 st February 2019). The primary outcome is 'linkage to care'. Secondary endpoints are retention in care, viral suppression, death and clinical failure at 6-12 months (up to 31 st August 2022). Self-reported stigma and depression are assessed using the Berger Stigma scale and the PHQ-9 questionnaire, respectively. The sample size calculation was based on cohort data from 2018. Assuming a pre-intervention cohort of 511 newly diagnosed adults of whom 346 (68%) were in care and on antiretroviral treatment (ART) at 2 months, a 10% increase in linkage (from 70 to 80%), a two-sided type I error rate of 5%, and 90% power, 321 adults are required for the post-implementation group. Discussion: We expect that integration of stigma-directed services leads to an increase of proportions of patients in care and on ART. The findings will provide guidance on how to integrate stigma-directed services into routine care in rural sub-Saharan Africa.

Impact of Disclosure over Time on the Emotional Well-Being of Children with Perinatally Acquired HIV Infection in South Africa

OBJECTIVE

The aim of this study was to describe the disclosure process in children with perinatally acquired HIV infection (PHIV+) and its impact on their emotional well-being and adherence to antiretroviral therapy (ART) in South Africa.

METHODS

This prospective cohort study followed PHIV+ children aged 7 to 13 years attending counseling over 18 months. Standardized disclosure tools were used by a counselor with both child and caregiver present. Assessments included the Child Behavior Checklist (CBCL), Vineland Adaptive Behavior Scale (VABS), Child Depression Inventory (CDI), and Revised Children's Manifest Anxiety Scale (RCMAS). Adherence to ART was recorded through pharmacy pill returns. Changes over time and their differences from baseline were assessed by linear mixed models.

RESULTS

Thirty children with median age 10 years (interquartile range [IQR]: 9.0-11.0) were enrolled. The median time to disclosure was 48 weeks (IQR: 48.0-54.6). There was a significant decrease from baseline (p < 0.0001) and over time (p = 0.0037) in the total CDI score. A positive trend in the changes from baseline and over time was observed for internalizing (p values < 0.0001) and externalizing (p values < 0.0001) CBCL scales and Total Anxiety score of the RCMAS (p < 0.0001 and p < 0.0002, respectively). Only the Defensiveness median T-score increased during the follow-up (p = 0.004) and in the change from baseline (p = 0.0005). The adaptive (p = 0.0092) and maladaptive (p < 0.0001) scores of the VABS showed a decrease from baseline. ART adherence remained high throughout this study.

CONCLUSION

Disclosure does not worsen the child's emotional well-being and adherence to ART over time. This study adds to research from low- and middle-income countries to alleviate fears that disclosure may have an adverse outcome on children with PHIV+.

Stigma-directed services (Stig2Health) to improve 'linkage to care' for people living with HIV in rural Tanzania: study protocol for a nested pre-post implementation study within the Kilombero and Ulanga Antiretroviral Cohort

Background: HIV-related stigma is a major barrier to the timely linkage and retention of patients in HIV care in sub-Saharan Africa, where most people living with HIV/AIDS reside. In this implementation study we aim to evaluate the effect of stigma-directed services on linkage to care and other health outcomes in newly diagnosed HIV-positive patients. Methods: In a nested project of the Kilombero and Ulanga Antiretroviral Cohort in rural Tanzania, we conduct a prospective observational pre-post study to assess the impact of a bundle of stigma-directed services for newly diagnosed HIV positive patients. Stigma-directed services, delivered by a lay person living with HIV, are i) post-test counseling, ii) post-test video-assisted teaching, iii) group support therapy and group health education, and iv) mobile health. Patients receiving stigma services (enrolled from 1 st February 2020 to 31 st August 2021) are compared to a historical control receiving the standard of care (enrolled from 1 st July 2017 to 1 st February 2019). The primary outcome is 'linkage to care'. Secondary endpoints are retention in care, viral suppression, death and clinical failure at 6-12 months (up to 31 st August 2022). Self-reported stigma and depression are assessed using the Berger Stigma scale and the PHQ-9 questionnaire, respectively. The sample size calculation was based on cohort data from 2018. Assuming a pre-intervention cohort of 511 newly diagnosed adults of whom 346 (68%) were in care and on antiretroviral treatment (ART) at 2 months, a 10% increase in linkage (from 70 to 80%), a two-sided type I error rate of 5%, and 90% power, 321 adults are required for the post-implementation group. Discussion: We expect that integration of stigma-directed services leads to an increase of proportions of patients in care and on ART. The findings will provide guidance on how to integrate stigma-directed services into routine care in rural sub-Saharan Africa.

Depression and Anxiety in Youth and Young Adults Living with HIV: Frequency and Associated Factors in Thai Setting

Integrative mental health care in HIV patients is an important contributor to successful therapy. This is a cross-sectional study in youth and young adults who attend routine HIV clinic at a tertiary care centre in Bangkok. We recruited 100 youth and 130 young adults living with HIV to evaluate the frequency of depression and anxiety and associated sociodemographic including sexual orientation and health-related behaviours. Overall, about a fifth of the participants had significant depression or anxiety. Interestingly, we found different factors associated with depression in youth and young adults living with HIV. Loss of their father, loss of close relatives or friends, and being unemployed or school exclusion were the factors associate with depression in youth; while dangerous alcohol use, feeling discriminated against and having lipodystrophy were factors in young adults. The understanding of the frequency and different associated factors can inform more effective prevention and treatment strategies.

Prevalence and factors associated with common mental disorders in young people living with HIV in sub-Saharan Africa: a systematic review

INTRODUCTION

Common mental disorders (CMDs) particularly depression and anxiety, are highly comorbid with HIV also in young people living with HIV (YLWH). In sub-Saharan Africa (SSA) where most YLWH reside, there are limited summary data on CMDs among these youths, yet there are previous systematic reviews summarizing data on CMDs among adults living with HIV. We conducted a systematic literature review on the prevalence and correlates of CMDs among YLWH, aged 10 to 24 years, from SSA.

METHODS

We searched African Index Medicus, African Journals Online and five other electronic databases (from database inception up to 31 December 2020) for relevant studies published in English. The key search terms applied were as follows: "Depression OR Anxiety", "Young people", "HIV infections" and "sub-Saharan Africa".

RESULTS AND DISCUSSION

Out of 3989 articles, 31 studies were included in the review. The prevalence of CMDs in YLWH widely varied ranging between 16.0% and 40.8% for major depression, 4.4% and 52.6% for depressive symptoms and 2.2% and 25.0% for anxiety symptoms. Anxiety disorder was estimated at 45.6%. Four of the five included studies with a comparison group of HIV-negative young people reported significantly higher prevalence estimates of depressive disorders among YLWH. Several sociodemographic, psychosocial and HIV-related correlates of CMDs were reported but most lacked consensus across studies. Nevertheless, female sex, older age, fewer schooling years, HIV-positive status, bullying, sexual abuse, HIV-related stigma, social support and poor antiretroviral therapy adherence were frequently reported (in ≥2 studies) as significant correlates of depressive symptoms among YLWH. Higher social support was the only frequent significant correlate of anxiety symptoms.

CONCLUSIONS

The burden of CMDs among YLWH from SSA is substantial and appears to be significantly higher when compared with HIV-negative peers, particularly for depressive disorders. However, more comparative research is needed. Importantly, screening for CMDs at the youth HIV-clinics should be prioritized especially for YLWH at high risk of CMDs, to facilitate early management or referral for treatment. Furthermore, youth-friendly psychological interventions addressing CMDs in YLWH should urgently be piloted in SSA, incorporating contextual components that may directly or indirectly reduce symptoms of CMDs among YLWH, such as social support.

Impact of Friendship Bench problem-solving therapy on adherence to ART in young people living with HIV in Zimbabwe: A qualitative study

BACKGROUND

Adolescents and young people globally are highly vulnerable to poor mental health especially depression, and they account for 36% of new HIV infections in Eastern and Southern Africa. HIV services remain inadequate for this population and their adherence to ART is low. The Friendship Bench (FB), an evidence-based model developed in Zimbabwe to bridge the mental health gap, is a brief psychological intervention delivered on benches in primary care facilities by lay health workers ("grandmothers") trained in problem-solving therapy. This study explored the experience of young people living with HIV attending FB, and their perception of how problem-solving therapy impacted their adherence to ART.

METHODS

Semi-structured interviews were conducted in July 2019 with 10 young people living with HIV aged 18-24 years, who had recently completed FB counselling in Harare. Participants were purposively sampled and recruited from three primary care facilities. Interviews were conducted in Shona, audio-recorded, transcribed verbatim and translated into English. Transcripts were analysed in NVivo12 using inductive thematic analysis.

RESULTS

Study findings revealed a clear emotional denial towards HIV, particularly for young people infected perinatally, and a resulting low adherence to ART. The study also unpacked the issues of internal stigma and how young people living with perinatally acquired HIV are informed of their HIV status. Participants reported that FB had a critical role in helping them accept their HIV status. Grandmothers' empathic attitude was key during counselling on adherence to ART, to demystify the disease and treatment, normalize the reality of living with HIV, encourage young people to socialize with peers and free them of guilt. Interviewees unanimously reported improved ART adherence following FB counselling, and many described enhanced health and wellbeing.

CONCLUSION

Participants saw FB as a strong contributor to their general well-being, evident in decreased symptoms of depression and improved adherence to ART. FB problem-solving therapy should be rolled out to further support young people after post-test counselling or HIV serostatus disclosure for perinatally acquired HIV, for acceptance of HIV status and adherence to ART.

Factors Associated with HIV Disclosure Status Among iENGAGE Cohort of New to HIV Care Patients

HIV disclosure is an important behavior with implications for HIV treatment and prevention but understudied among new to HIV care patients who face unique challenges adjusting to a new diagnosis. This study evaluated the factors associated with HIV disclosure status and patterns of HIV disclosure among new to HIV care patients. A cross-sectional study was conducted evaluating the iENGAGE (integrating ENGagement and Adherence Goals upon Entry) cohort. Participants were enrolled in this randomized behavioral trial between December 2013 and June 2016. The primary and secondary outcomes included HIV disclosure status (Yes/No) and patterns of disclosure (Broad, Selective and Nondisclosure), respectively. Logistic and Multinomial Logistic Regression were used to evaluate the association of participant factors with HIV disclosure and patterns of HIV disclosure, respectively. Of 371 participants, the average age was 37 ± 12 years, 79.3% were males, and 62.3% were African Americans. A majority of participants (78.4%) disclosed their HIV status at baseline, 63.1% were broad disclosers and 15.2% were selective disclosers. In multivariable regression, black race, emotional support, and unmet needs predicted any HIV and broad disclosure, whereas males, emotional support, active coping, and acceptance were associated with selective disclosure. Interventions to promote early disclosure should focus on coping strategies and unmet needs, particularly among black and male people living with HIV initiating care.

Experiences and effects of HIV-related stigma among youth living with HIV/AIDS in Western Uganda: A photovoice study

HIV-related stigma has been identified as a significant stressor affecting Quality of Life of Youth Living With HIV/AIDS (YLWHA). Gaining a contextualized understanding of how this stigma is experienced by YLWHA in Western Uganda is crucial in addressing it in this group and setting. In this study, we explored the lived experiences of YLWHA with HIV-related stigma. Photovoice was used to gain insight into the lived experiences of HIV-related stigma in 11 YLWHA (15–19 years), purposively selected from a hospital-based peer support group. Group interview transcripts, notes and photographs were subjected to phenomenological hermeneutic analysis. Encounters with enacted, anticipated and internalized stigmas and their myriad sequels were prevalent in the photos and narratives of participants. Our findings were categorized and presented in 5 main themes that were identified through the analysis: being devalued, experiencing fear, experiencing injustices, feeling lonely, and lacking future perspectives. HIV-related stigmas were experienced in various socio-ecological domains but predominantly in homes and schools that ought to be supportive surroundings for youths. A multilevel approach, targeting the entire society where the root causes of stigma can be found and specific contexts like schools and homes where youth are confronted with stigma on a daily basis is proposed for a wholistic intervention.

The prevalence of mental health problems in sub-Saharan adolescents living with HIV: a systematic review

Despite the progress made in HIV treatment and prevention, HIV remains a major cause of adolescent morbidity and mortality in sub-Saharan Africa. As perinatally infected children increasingly survive into adulthood, the quality of life and mental health of this population has increased in importance. This review provides a synthesis of the prevalence of mental health problems in this population and explores associated factors. A systematic database search (Medline, PsycINFO, Scopus) with an additional hand search was conducted. Peer-reviewed studies on adolescents (aged 10-19), published between 2008 and 2019, assessing mental health symptoms or psychiatric disorders, either by standardized questionnaires or by diagnostic interviews, were included. The search identified 1461 articles, of which 301 were eligible for full-text analysis. Fourteen of these, concerning HIV-positive adolescents, met the inclusion criteria and were critically appraised. Mental health problems were highly prevalent among this group, with around 25% scoring positive for any psychiatric disorder and 30-50% showing emotional or behavioral difficulties or significant psychological distress. Associated factors found by regression analysis were older age, not being in school, impaired family functioning, HIV-related stigma and bullying, and poverty. Social support and parental competence were protective factors. Mental health problems among HIV-positive adolescents are highly prevalent and should be addressed as part of regular HIV care.

Challenges and facilitators of transition from adolescent to adult HIV care among young adults living with HIV in Moshi, Tanzania

INTRODUCTION

Scale up of anti-retroviral therapy has enabled millions of children infected with HIV to survive into adulthood, requiring transition of care to the adult HIV clinic. This transition period is often met with anxiety and reluctance. Youth who fail to transition may create strain on capacity in the pediatric and adolescent clinics or result in individuals dropping out of care entirely. This study examined challenges and facilitators to the transition among young adults living with HIV in Moshi, Tanzania.

METHODS

From April to June 2017, in-depth interviews were conducted with young adults aged 18 to 27 years living with HIV in order to capture the spectrum of experiences from pre-transitioning youth to those who successfully transitioned to adult care. Young adults were purposively recruited based on prior study enrollees and recommendations from healthcare staff. Recruitment occurred in the adolescent, adult HIV and the prevention of mother to child transition clinics at Kilimanjaro Christian Medical Centre. Two separate in-depth interviews were conducted with eligible participants. Medical records were reviewed retrospectively to collect information on HIV-related outcomes.

RESULTS

In-depth interviews were held with 19 young adults. Participants mean age was 23.8 years (interquartile range 22.2 to 26.3 years); 53% were female. Most (78.9%) participants had been receiving anti-retroviral therapy for nearly a decade and 72.2% were virologically suppressed (HIV RNA <200 copies/mL). Barriers to transition included fear of losing peer networks formed in the adolescent clinic, the abrupt manner in which young adults were asked to transition, stigma, financial constraints and a lower quality of care in the adult clinic. Facilitators of transition included family and social support, positive perspectives on living with HIV and maintenance of good health. Recommendations for transition included transition preparation, transition as a group and adoption of desirable aspects of the adolescent clinic (peer networks and education) in the adult clinic.

CONCLUSIONS

Transition is a complex process influenced by many factors. As the number of young adults living with HIV continues to grow, it is vital to develop a transition protocol that addresses these challenges and is feasible to implement in low-resource settings.

Barriers to HIV Treatment Adherence: A Qualitative Study of Discrepancies Between Perceptions of Patients and Health Providers in Tanzania and Uganda

Previous qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers-particularly in low-income countries-who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n = 148), and with health care providers (n = 49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (e.g., they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.

HIV-1 Drug Resistance and Virologic Outcomes Among Tanzanian Youth Living With HIV

Adolescents living with HIV tend to have poor adherence that often breeds HIV resistance mutations and virologic failure (VF). This study evaluated risk behavior, virologic outcomes and HIV resistance mutations in Tanzanian youth living with HIV. Participants were primarily perinatally infected and of mean age 16.7 years; among them 41.5% had VF. Those receiving first-line therapy demonstrated over 90% resistance to their current therapy.

Building resilience: a mental health intervention for Tanzanian youth living with HIV

Despite a growing population of youth living with HIV, few interventions have been developed to address their unique mental health needs and to promote resilience. Based on our prior needs assessment, a mental health intervention, Sauti ya Vijana ( The Voice of Youth), was developed to address identified mental health needs and promote resilience. The intervention emphasized resilience strategies for identifying and coping with stressful events, supporting strong familial and social relationships, and planning for a safe and healthy living environment through stigma reduction, planning for disclosure, and instilling hope for the future. Ten group sessions (two of which were joint youth/caregiver sessions) and two individual sessions were developed around these three resilience domains. Youth living with HIV (average age 17.4 years), who were receiving antiretroviral therapy and attending HIV adolescent clinic in Tanzania were randomized to intervention or treatment as usual. Trained group leaders led the intervention sessions. Near perfect program fidelity by the group leaders and unanimous acceptance of the intervention by the youth was documented. SYV successfully promoted youth resilience as measured by youth-reported utilization of new coping skills, improved peer and caregiver relationships, reduced stigma, and improved confidence to live positively according to their personal values.

Caregiver role in HIV medication adherence among HIV-infected orphans in Tanzania

Youth living with HIV in sub-Saharan Africa face numerous challenges in adhering to HIV treatment. The AIDS epidemic has left many of these youth orphaned due to AIDS-related death of one or both parents. It is imperative to understand the family context of youth living with HIV in order to develop responsive interventions to improve adherence to antiretroviral therapy. We conducted qualitative in-depth interviews with 17 HIV-infected AIDS orphans, ages 13-24 years, screened positive for mental health difficulties according to the Patient Health Questionaire-9 (PHQ-9) or UCLA PTSD Reaction Index (PTSD-RI), and receiving outpatient HIV care at an adolescent medical clinic in Moshi, Tanzania. Treatment-related support varied by orphan status. Paternal orphans cared for by their biological mothers and maternal orphans cared for by grandmothers described adherence support such as assistance taking medication and attending clinic. Double orphans did not report adherence support. Several maternal and double orphans faced direct interference from caregivers and household members when they attempted to take their medications. Caregivers play a significant role in treatment adherence and must be considered in interventions to increase medication adherence in HIV-infected orphans. Findings from this study informed caregiver participation in Sauti ya Vijana (The Voice of Youth), a mental health intervention for youth living with HIV in Tanzania.