Mental, Neurological, and Substance Use Disorders in People Living With HIV/AIDS in Low- and Middle-Income Countries

Structural and Functional Dysregulation of the Brain Endothelium in HIV Infection and Substance Abuse

Blood-brain barrier (BBB) injury and dysfunction following infection with the human immunodeficiency virus (HIV) enables viral entry into the brain, infection of resident brain cells, neuronal injury and subsequent neurodegeneration leading to HIV-associated neurocognitive disorders (HAND). Although combination antiretroviral therapy has significantly reduced the incidence and prevalence of acquired immunodeficiency syndrome and increased the life expectancy of people living with HIV, the prevalence of HAND remains high. With aging of people living with HIV associated with increased comorbidities, the prevalence of HIV-related central nervous system (CNS) complications is expected to remain high. Considering the principal role of the brain endothelium in HIV infection of the CNS and HAND, the purpose of this manuscript is to review the current literature on the pathobiology of the brain endothelium structural and functional dysregulation in HIV infection, including in the presence of HIV-1 and viral proteins (gp120, Tat, Nef, and Vpr). We summarize evidence from human and animal studies, in vitro studies, and associated mechanisms. We further summarize evidence of synergy or lack thereof between commonly abused substances (cocaine, methamphetamine, alcohol, tobacco, opioids, and cannabinoids) and HIV- or viral protein-induced BBB injury and dysfunction.

HIV-associated neurocognitive disorder: key implications of the microbiota-gut-brain axis

HIV-associated neurocognitive disorder (HAND) is now recognized to be relatively common in people living with HIV (PLWH), and remains a common cause of cognitive impairment. Unfortunately, the fundamental pathogenic processes underlying this specific outcome of HIV infection have not as yet been fully elucidated. With increased interest in research related to the microbiota-gut-brain axis, the gut-brain axis has been shown to play critical roles in regulating central nervous system disorders such as Alzheimer's disease and Parkinson's disease. PLWH are characterized by a particular affliction, referred to as gut-associated dysbiosis syndrome, which provokes an alteration in microbial composition and diversity, and of their associated metabolite composition within the gut. Interestingly, the gut microbiota has also been recognized as a key element, which both positively and negatively influences human brain health, including the functioning and development of the central nervous system (CNS). In this review, based on published evidence, we critically discuss the relevant interactions between the microbiota-gut-brain axis and the pathogenesis of HAND in the context of HIV infection. It is likely that HAND manifestation in PLWH mainly results from (i) gut-associated dysbiosis syndrome and a leaky gut on the one hand and (ii) inflammation on the other hand. In other words, the preceding features of HIV infection negatively alter the composition of the gut microbiota (microbes and their associated metabolites) and promote proinflammatory immune responses which singularly or in tandem damage neurons and/or induce inadequate neuronal signaling. Thus, HAND is fairly prevalent in PLWH. This work aims to demonstrate that in the quest to prevent and possibly treat HAND, the gut microbiota may ultimately represent a therapeutically targetable "host factor."

Cognitive interviewing to assess and adapt three measures of mental health symptoms among people living with HIV in Rakai, Uganda: the Thinking a Lot Questionnaire, the Patient Health Questionnaire 9 (PHQ-9), and the Hopkins Symptoms Checklist (HSCL)

Mental health is conceptualized differently across cultures, making cross-cultural validation of screening tools critical. In Uganda, we used cognitive interviewing to assess and adapt three scales for measuring psychological distress: the Thinking a Lot Questionnaire, the Patient Health Questionnaire 9 (PHQ-9), and the Hopkins Symptoms Checklist (HSCL). We recruited 12 people living with HIV from the Rakai Community Cohort Study (RCCS) and interviewed seven potential users of the scales (four RCCS survey interviewers and three local health workers). Data were analyzed systematically using a team-based matrix approach. The HSCL was generally well understood, with minor clarifications needed. The Thinking a Lot Questionnaire was also well understood, though differences between "how much" and "how often" required specificity. Both included local idioms of distress from prior adaptations. The PHQ-9 performed less well, with many questions interpreted variably or showing unclear local applicability, especially among people living with HIV. For example, questions about trouble concentrating were misunderstood, focusing on examples like newspapers rather than the broader issue of concentration. Future research should explore the validity and utility of commonly used instruments as mental health research expands in Africa.

Mental health and cognition in relation to adherence to antiretroviral therapy among people living with HIV in Kazakhstan: a cross-sectional study

INTRODUCTION

There is a research gap in how mental health and cognition are associated with antiretroviral treatment (ART) adherence among people living with HIV (PLWH) in Kazakhstan.

METHODS

We randomly selected and enrolled 230 PLWH from the Almaty City AIDS Center registry (June-November 2019) into a cross-sectional study. We examined associations between self-reported ART adherence for the last 1 and 2 weeks; the Adherence Self-Efficacy Scale (ASES) and symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder tool [GAD-7]), post-traumatic stress disorder (PTSD Checklist [PTSD]); cognitive function (PROMIS v2.0 Adult Cognitive Function 8a short form) and forgetfulness (Forgetfulness Assessment Inventory). We used cut points of ≥5 for at least mild and ≥10 for at least moderate symptom severity for PHQ-9 and GAD-7 and of ≥44 for PTSD. Logistic and linear regression analyses were used.

RESULTS

Participants' median age was 40.0 (IQR: 34-47) with 40.9% (n = 94) of females in the sample. Those who missed at least one pill for the last 2 weeks had higher odds of reporting at least mild depression (aOR = 3.34, 95% CI: 1.22-9.11, p < 0.05); mild anxiety (aOR = 3.27, 95% CI: 1.20-8.92, p < 0.05); and PTSD (aOR = 4.04, 95% CI: 1.15-14.21, p < 0.05) symptoms. Participants who missed at least one pill for the last week had higher odds of at least mild depression (aOR = 7.74, 95% CI: 1.31-45.7, p < 0.05), moderate anxiety (aOR = 21.33, 95% CI: 3.24-140.33, p < 0.005) and PTSD (aOR = 13.81, 95% CI: 2.36-80.84, p < 0.005) symptoms. Participants with better cognitive function had lower odds of non-adherence over the last week (aOR = 0.88, 95% CI: 0.81-0.96, p < 0.005) and higher ASES scores (β = 0.26, 95% CI: 0.13-0.40, p < 0.005). Poor memory was associated with higher odds of non-adherence over the last week (aOR = 4.64, 95% CI: 1.76-12.24, p < 0.005) and lower ASES score (β = -0.31, 95% CI: -0.45 to 0.16, p < 0.005). Those who had at least mild depression (β = -0.21, 95% CI: -0.35 to -0.07, p < 0.005); moderate anxiety (β = -0.21, 95% CI: -0.34 to -0.07, p < 0.005) and PTSD (β = -0.19, 95% CI: -0.33 to -0.05, p < 0.005) symptoms had lower ASES scores.

CONCLUSIONS

Depression, anxiety and PTSD symptoms, poorer cognition, and forgetfulness were associated with poorer ART adherence and worse adherence self-efficacy. It is crucial to assess and treat mental illness and provide support for PLWH with worsened cognition to enhance ART adherence.

Antenatal depression and its predictors among HIV positive women in Sub-Saharan Africa; a systematic review and meta-analysis

Background

Antenatal depression in Human Immunodeficiency Virus (HIV) positive pregnant women can have significant adverse effects on both the mother and newborns, yet it is often overlooked in pregnancy care in Sub-Saharan Africa (SSA). Despite this, there is limited data on the combined prevalence of antenatal depression and its predictors among HIV-positive women in the region.

Objective

To assess the pooled prevalence of antenatal depression and its associated factors among HIV-positive women in SSA.

Methods

All primary cross-sectional studies published before 1st January/2024, were included. We conducted searches in relevant databases; PubMed, HINARI, Web of Science, PsycINFO, Psychiatry Online, ScienceDirect, and Google Scholar. The Joanna Briggs Institute checklist was used to critically appraise the selected studies. To assess heterogeneity among the studies, we utilized the I2 test. Publication bias was evaluated using a funnel plot and Egger's test. The forest plot was used to present the combined proportion of antenatal depression and odds ratio, along with a 95% confidence interval.

Results

The pooled prevalence of antenatal depression among HIV-positive women in Sub-Saharan Africa was found to be 30.6% (95% CI, 19.8%-41.3%). Factors significantly associated with antenatal depression among HIV-positive women in SSA included being unmarried (AOR: 3.09, 95% CI: 1.57 - 6.07), having a previous history of depression (AOR: 2.97, 95% CI: 1.79 - 4.91), experiencing intimate partner violence (IPV) (AOR: 2.11, 95% CI: 1.44 - 3.09), and experiencing stigma (AOR: 1.36, 95% CI: 1.05 - 1.76).

Conclusion

High prevalence of antenatal depression among HIV-positive women in SSA underscores the need for prioritizing identification and management. Interventions addressing factors like IPV and stigma, along with training for healthcare providers in recognizing symptoms and providing support, are recommended.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42024508236.

An mHealth Intervention to Address Depression and Improve Antiretroviral Therapy Adherence Among Youths Living With HIV in Uganda: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

People living with HIV often struggle with mental health comorbidities that lower their antiretroviral therapy (ART) adherence. There is growing evidence that depression treatment may improve ART adherence and result in improved HIV outcomes. Given that mental health services are severely underequipped in low-resource settings, including in Uganda, new solutions to increase access to mental health care and close the treatment gap are urgently needed. This protocol paper presents the Suubi-Mhealth study, which proposed to develop a mobile health (mHealth) intervention for use among Ugandan youths (14-17 years) with comorbid HIV and depression, taking into account their unique contextual, cultural, and developmental needs.

OBJECTIVE

The proposed study is guided by the following objectives: (1) to develop and iteratively refine an intervention protocol for Suubi-Mhealth based on formative work to understand the needs of youths living with HIV; (2) to explore the feasibility and acceptability of Suubi-Mhealth on a small scale to inform subsequent refinement; (3) to test the preliminary impact of Suubi-Mhealth versus a waitlist control group on youths' outcomes, including depression and treatment adherence; and (4) to examine barriers and facilitators for integrating Suubi-Mhealth into health care settings.

METHODS

Youths will be eligible to participate in the study if they are (1) 14-17 years of age, (2) HIV-positive and aware of their status, (3) receiving care and ART from one of the participating clinics, and (4) living within a family. The study will be conducted in 2 phases. In phase 1, we will conduct focus group discussions with youths and health care providers, for feedback on the proposed intervention content and methods, and explore the feasibility and acceptability of the intervention. In phase II, we will pilot-test the preliminary impact of the intervention on reducing depression and improving ART adherence. Assessments will be conducted at baseline, 1-, 2-, and 6-months post intervention completion.

RESULTS

Participant recruitment for phase 1 is completed. Youths and health care providers participated in focus group discussions to share their feedback on the proposed Suubi-Mhealth intervention content, methods, design, and format. Transcription and translation of focus group discussions have been completed. The team is currently developing Suubi-Mhealth content based on participants' feedback.

CONCLUSIONS

This study will lay important groundwork for several initiatives at the intersection of digital therapeutics, HIV treatment, and mental health, especially among sub-Saharan African youths, as they transition through adolescence and into adult HIV care settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05965245; https://clinicaltrials.gov/study/NCT05965245.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54635.

Cocaine regulates antiretroviral therapy CNS access through pregnane-x receptor-mediated drug transporter and metabolizing enzyme modulation at the blood brain barrier

BACKGROUND

Appropriate interactions between antiretroviral therapies (ART) and drug transporters and metabolizing enzymes at the blood brain barrier (BBB) are critical to ensure adequate dosing of the brain to achieve HIV suppression. These proteins are modulated by demographic and lifestyle factors, including substance use. While understudied, illicit substances share drug transport and metabolism pathways with ART, increasing the potential for adverse drug:drug interactions. This is particularly important when considering the brain as it is relatively undertreated compared to peripheral organs and is vulnerable to substance use-mediated damage.

METHODS

We used an in vitro model of the human BBB to determine the extravasation of three first-line ART drugs, emtricitabine (FTC), tenofovir (TFV), and dolutegravir (DTG), in the presence and absence of cocaine, which served as our illicit substance model. The impact of cocaine on BBB integrity and permeability, drug transporters, metabolizing enzymes, and their master transcriptional regulators were evaluated to determine the mechanisms by which substance use impacted ART central nervous system (CNS) availability.

RESULTS

We determined that cocaine had a selective impact on ART extravasation, where it increased FTC's ability to cross the BBB while decreasing TFV. DTG concentrations that passed the BBB were below quantifiable limits. Interestingly, the potent neuroinflammatory modulator, lipopolysaccharide, had no effect on ART transport, suggesting a specificity for cocaine. Unexpectedly, cocaine did not breach the BBB, as permeability to albumin and 4 kDa FITC-dextran, as well as tight junction proteins and adhesion molecules remained unchanged. Rather, cocaine selectively decreased the pregnane-x receptor (PXR), but not constitutive androstane receptor (CAR). Consequently, drug transporter expression and activity decreased in endothelial cells of the BBB, including p-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and multidrug resistance-associated protein 4 (MRP4). Further, cytochrome P450 3A4 (CYP3A4) enzymatic activity increased following cocaine treatment that coincided with decreased expression. Finally, cocaine modulated adenylate kinases that are required to facilitate biotransformation of ART prodrugs to their phosphorylated, pharmacologically active counterparts.

CONCLUSION

Our findings indicate that additional considerations are needed in CNS HIV treatment strategies for people who use cocaine, as it may limit ART efficacy through regulation of drug transport and metabolizing pathways at the BBB.

Longitudinal trajectories of depressive symptoms among alcohol consuming men with HIV in India

BACKGROUND

Depression and alcohol use are common among people living with HIV (PLWH) and associated with adverse outcomes. However, there is a paucity of studies exploring trajectories of depressive symptom presence over time among alcohol consuming men PLWH.

METHODS

Men PLWH were repeatedly assessed for depressive symptoms from baseline through 27 months using the 10-item Center for Epidemiologic Studies-Depression scale. Group-based trajectory modeling was used to identify trajectories of depressive symptoms over time among control (n = 188) and intervention participants (n = 564). Multinomial logistic regression was used to explore the relationship between trajectory subgroups and baseline independent variables.

RESULTS

Among intervention participants, the three subgroups were characterized as 'low' (85.8 % of the participants), 'fluctuating' (8.7 %), and 'persistently increasing' symptoms (5.5 %). Similarly, three trajectory subgroups among control participants were labeled as: "low" (54.4 %); "fluctuating" (33.5 %) and "persistently increasing'" (12.1 %). Among intervention participants, longer duration since HIV diagnosis (aOR: 1.05, 95 % CI: 1.01-1.12) and HIV-related stigma (aOR: 1.09, 95 % CI: 1.02-1.18) were associated with persistently increasing depressive symptoms trajectory. Further, alcohol drinking problems (aOR: 1.10, 95 % CI: 1.04-1.17) was associated with fluctuating depressive symptoms trajectory. Among control participants, only lower overall self-rated health status was associated with persistently increasing depressive symptoms trajectory (aOR: 0.96, 95 % CI: 0.93-0.99).

LIMITATIONS

Selection bias; Information bias; Lack of causal interference; Generalizability.

CONCLUSION

Identifying subgroups of men PLWH with different depressive symptoms trajectories may inform effective and tailored intervention approaches to address mental health treatment and prevention among alcohol consuming men PLWH in India and elsewhere.

Effectiveness of trauma-focused cognitive behavioral therapy compared to psychosocial counseling in reducing HIV risk behaviors, substance use, and mental health problems among orphans and vulnerable children in Zambia: a community-based randomized controlled trial

Orphans and vulnerable children (OVC) in sub-Saharan Africa are at high risk for HIV infection and transmission. HIV prevention and treatment efforts with OVC are hindered by mental health and substance use problems. This randomized controlled trial compared a mental health intervention, Trauma Focused Cognitive Behavioral Therapy (TF-CBT), to an enhanced version of an existing HIV Psychosocial Counseling (PC+) program among 610 adolescents who met PEPFAR criteria for OVC and had HIV risk behaviors in Lusaka, Zambia. Outcomes included HIV risk behaviors (e.g., risky sexual behaviors), mental health (internalizing symptoms, externalizing behaviors, PTSD) and substance use. At 12-month follow-up, there were significant within group reductions in both groups for all outcomes, with the only significant between group difference being for substance use, in which OVC who received TF-CBT had significantly greater reductions than OVC who received PC+. In a subgroup analysis of OVC with high levels of PTSD symptoms, TF-CBT was superior to PC + in reducing internalizing symptoms, functional impairment, and substance use. Findings support TF-CBT for reducing substance use among OVC. Subgroup analysis results suggest that a robust intervention such as TF-CBT is warranted for OVC with significant mental and behavioral health comorbidities. The similar performance of TF-CBT and PC + in the overall sample for risky sexual behavior and mild mental health problems indicates that enhancing existing psychosocial programs, such as PC, with standard implementation factors like having a defined training and supervision schedule (as was done to create PC+) may improve the efficacy of HIV risk reduction efforts.Clinical Trials Number: NCT02054780.

Addressing the unmet mental health needs of people living with HIV: a scoping review of interventions in sub-Saharan Africa

Some mental health interventions have addressed mental health among people living with HIV (PLWH) using a variety of approaches, but little is known about the details of such interventions in sub-Saharan Africa (SSA), a region that bears the largest burden of HIV in the world. The present study describes mental health interventions for PLWH in SSA regardless of the date and language of publication. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guidelines, we identified 54 peer-reviewed articles on interventions addressing adverse mental health conditions among PLWH in SSA. The studies were conducted in 11 different countries, with the highest number of studies in South Africa (33.3%), Uganda (18.5%), Kenya (9.26%), and Nigeria (7.41%). While only one study was conducted before the year 2000, there was a gradual increase in the number of studies in the subsequent years. The studies were mostly conducted in hospital settings (55.5%), were non-pharmacologic (88.9%), and interventions were mostly cognitive behavioural therapy (CBT) and counselling. Task shifting was the primary implementation strategy used in four studies. Interventions addressing the mental health needs of PLWH that incorporates the unique challenges and opportunities in SSA is highly recommended.

The REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Protocol: Using a Universal Screener to Improve Mental Health and Enhance HIV Care Outcomes

Among people living with HIV (PLWH), 50% report substance use disorders (SUDs), and 30-61% report posttraumatic stress disorder (PTSD). Comorbid PTSD/SUD/HIV has been linked to faster HIV progression and twice the rate of death, lower medical adherence and retention, and increased viral load compared to PLWH without co-occurring PTSD or SUD. A critical first step in establishing comprehensive mental health services for PLWH is the implementation of an evidence-based screening protocol for PTSD and SUDs to facilitate referrals to specialty mental health providers. Guided by the Consolidated Framework for Implementation Research, this mixed-methods study aimed to examine the feasibility of delivering the REACH (Resiliency, Engagement, and Accessibility for Comorbid HIV/PTSD/SUD populations) Screening protocol. Three case managers were instructed to provide the REACH screening electronically to all patients that they saw for enrollment or re-enrollment appointments over 3 months (n=102). Of the 70 patients who completed the screener, 27% had clinically significant PTSD symptoms and 48.6% had SUD concerns. Qualitative feedback revealed themes related to beliefs about SU and PTSD, attitudes toward screening, comfort in the discussion of SU and PTSD, and referral and treatment considerations. Discussion includes lessons learned for implementation of this assessment of PTSD/SUD in PLWH as a novel approach to increase mental health engagement and promote health equity, with the potential long-term impact of improving HIV care outcomes via ameliorating mental health/SUD, and implications for prevention of HIV transmission. Implementation science can be leveraged to understand the gap in the utilization of existing evidence-based screening tools in HIV care settings.

Higher rates of mental health screening of adolescents recorded after provider training using simulated patients in a Kenyan HIV clinic: results of a pilot study

Background

Kenyan adolescent girls and young women (AGYW) experience a dual burden of HIV and common mental disorders (CMD). HIV clinics are a key entry point for AGYW in need of integrated CMD and HIV care; however, rates of screening and referral for CMDs are low. Our objective was to test an evidence-based provider training strategy, simulated patient encounters (SPEs), on CMD service delivery for AGYW in a Kenyan HIV clinic.

Methods

This pilot study was conducted in a public HIV clinic in Thika, Kenya from January to November 2021. The simulated patient encounter (SPE) implementation strategy included case script development from prior qualitative work, patient actor training, and a three-day SPE training including four standardized mock clinical encounters followed by quantitative surveys assessing provider competencies for each encounter. We abstracted medical record data related to HIV and CMDs such as HIV status, reason for visit, CMD screening test performed, and counselling or referral information. We conducted an interrupted time series analysis using abstracted HIV and CMD screening rates from AGYW ages 16-25 years visiting the clinic 7 months before and 3 months after SPE training. We used generalized linear models to assess changes in CMD screening rates after training.

Results

A total of 10 providers participated in the training. Competency ratings improved across four mock encounters (mean score from 8.1 to 13.7) between first and fourth encounters. We abstracted all medical records (n = 1,154) including from 888 (76%) AGYW seeking HIV treatment, 243 (21%) seeking prevention services, and 34 (3%) seeking other services. CMD screening rates increased immediately following training from 8 to 21% [relative risk (RR) = 2.57, 95% confidence interval (CI) = 1.34-4.90, p < 0.01]. The 3 months following the SPE training resulted in an 11% relative increase in CMD screening proportion compared to the 7 months pre-SPE (RR: 1.11, 95% CI: 1.04-1.17, p < 0.01). Finally, 1% of all pre-SPE screens resulted in referral versus 5% of post-SPE screens (p = 0.07).

Conclusion

The SPE model is a promising implementation strategy for improving HIV provider competencies and CMD service delivery for adolescents in HIV clinics. Future research is needed to explore effects on adolescent clinical outcomes in larger trials.

The Moderating Role of Social Support and HIV Stigma on the Association Between Depression and ART Adherence Among Young Thai Men Who Have Sex with Men

In Thailand, antiretroviral therapy (ART) programs still have difficulties reaching and promoting adherence among a key population - young men who have sex with men (YMSM) living with HIV. As such, we sought to examine potential psychosocial barriers that may contribute to suboptimal levels of ART adherence for this population. Data were drawn from a study of 214 YMSM living with HIV from Bangkok, Thailand. Linear regression models tested the association between depression and ART adherence, and whether social support and HIV-related stigma moderated that relationship. Multivariable models demonstrated social support was significantly associated with higher levels of ART adherence, and that there was a three-way interaction between depression, social support, and HIV-related stigma on ART adherence. These results further our understanding of the role of depression, stigma, and social support in ART adherence among Thai YMSM living with HIV, and that additional supports for YMSM with depression and HIV-related stigma are needed.

Cocaine Regulates Antiretroviral Therapy CNS Access Through Pregnane-X Receptor-Mediated Drug Transporter and Metabolizing Enzyme Modulation at the Blood Brain Barrier

Background

Appropriate interactions between antiretroviral therapies (ART) and drug transporters and metabolizing enzymes at the blood brain barrier (BBB) are critical to ensure adequate dosing of the brain to achieve HIV suppression. These proteins are modulated by demographic and lifestyle factors, including substance use. While understudied, illicit substances share drug transport and metabolism pathways with ART, increasing the potential for adverse drug:drug interactions. This is particularly important when considering the brain as it is relatively undertreated compared to peripheral organs and is vulnerable to substance use-mediated damage.

Methods

We used an in vitro model of the human BBB to determine the extravasation of three first-line ART drugs, emtricitabine (FTC), tenofovir (TFV), and dolutegravir (DTG), in the presence and absence of cocaine, which served as our illicit substance model. The impact of cocaine on BBB integrity and permeability, drug transporters, metabolizing enzymes, and their master transcriptional regulators were evaluated to determine the mechanisms by which substance use impacted ART central nervous system (CNS) availability.

Results

We determined that cocaine had a selective impact on ART extravasation, where it increased FTC's ability to cross the BBB while decreasing TFV. DTG concentrations that passed the BBB were below quantifiable limits. Interestingly, the potent neuroinflammatory modulator, lipopolysaccharide, had no effect on ART transport, suggesting a specificity for cocaine. Unexpectedly, cocaine did not breach the BBB, as permeability to albumin and tight junction proteins and adhesion molecules remained unchanged. Rather, cocaine selectively decreased the pregnane-x receptor (PXR), but not constitutive androstane receptor (CAR). Consequently, drug transporter expression and activity decreased in endothelial cells of the BBB, including p-glycoprotein (P-gp), breast cancer resistance protein (BCRP), and multidrug resistance-associated protein 4 (MRP4). Further, cytochrome P450 3A4 (CYP3A4) enzymatic activity increased following cocaine treatment that coincided with decreased expression. Finally, cocaine modulated adenylate kinases are required to facilitate biotransformation of ART prodrugs to their phosphorylated, pharmacologically active counterparts.

Conclusion

Our findings indicate that additional considerations are needed in CNS HIV treatment strategies for people who use cocaine, as it may limit ART efficacy through regulation of drug transport and metabolizing pathways at the BBB.

Association between mental disorders and adherence to antiretroviral treatment in health facilities in two Mozambican provinces in 2018: a cross-sectional study

INTRODUCTION

Lower adherence to antiretroviral treatment (ART) has been found among people with HIV (PWH) who have comorbid mental disorders like depression and alcohol use in Sub-Saharan African. However, there has been less exploration with regards to other mental disorders.

METHODS

This study assessed the association of multiple mental disorders and adherence to ART based on the data from primary/tertiary health care facilities in Maputo and Nampula, Mozambique. We administered a sociodemographic questionnaire, Mini International Neuropsychiatric Interview (MINI) Plus 4.0.0 adapted for use in Mozambique to assess mental conditions, and a 3-item self-report to measure ART adherence.

RESULTS

395 HIV-positive (self-report) participants on ART, with an average age of 36.7 years (SD = 9.8), and 30.4% were male. The most common mental disorders were major depressive disorder (27.34%) followed by psychosis (22.03%), suicidal ideation/behavior (15.44%), and alcohol-use disorder (8.35%). Higher odds of missing at least one dose in the last 30 days (OR = 1.45, 95% CI: 1.01, 2.10) were found in participants with any mental disorder compared to those without a mental disorder. The highest levels of non-adherence were observed among those with drug use disorders and panic disorder.

CONCLUSIONS

In Mozambique, PWH with any co-occurring mental conditions had a lower probability of ART adherence. Integrating comprehensive mental health assessment and treatment and ART adherence interventions tailored to PWH with co-occurring mental disorders is necessary to attain optimal ART adherence and reach the UNAIDS ART target.

Association of mental health symptoms on HIV care outcomes and retention in treatment

OBJECTIVE

The purpose was to examine associations between HIV care engagement and mental health symptoms among persons living with HIV (PLWH) receiving ART. This study builds upon previous findings indicating a significant association between mental health and retention in HIV care,¹ while also advancing the literature by examining the impact of substance use on this link, as well as potential bidirectional associations.

METHOD

Participants of the current study were 493 patients who engaged in care and received antiviral therapy (ART) from Infectious Disease physicians between 2017 and 2019 in a large academic medical center.

RESULTS

Results from hierarchical regression analyses revealed that patients who missed more days of ART medication had higher depressive symptoms, even when accounting for the effect of demographic variables and alcohol use. Further, depressive symptoms predicted significant variance in number of "no show" visits, but was not individually predictive of ""no show"" visits beyond the effect of other HIV care outcomes (e.g., number of days of medication missed).

CONCLUSION

Findings reflect linkages among HIV treatment adherence, mental health, and substance use, and highlight the need to target mental health symptoms to improve outcomes among PLWH and prevent HIV transmission.

Brief Report: Sex Differences in the Association Between Cerebrovascular Function and Cognitive Health in People Living With HIV in Urban China

BACKGROUND

Cardiometabolic and cerebrovascular disease are strong independent contributors to cognitive impairment in people living with HIV. Data suggest that cardiovascular risk may play a greater role in cognitive health in women than in men with HIV.

METHODS

We performed a cross-sectional study of 104 participants with virologically suppressed HIV from 2 clinics in urban China. Participants underwent neuropsychological testing from which we calculated T scores globally and in 5 cognitive domains. We assessed cerebral vasoreactivity of the middle cerebral arteries in response to breath holding. We constructed linear regression models to determine associations between cerebrovascular and cognitive function overall and stratified by sex.

RESULTS

Women were younger than men (48 versus 51 years, P = 0.053), had fewer years of education (9 years versus 12 years, P = 0.004), and fewer cardiometabolic risk factors (0 versus 1 factor, P = 0.008). In a model with all participants, cerebrovascular function was significantly associated with global cognition (2.74 higher T score per 1-point higher cerebral vasoreactivity [SE 1.30], P = 0.037). Cerebrovascular function remained significantly associated with global cognition among women (4.15 higher T score [SE 1.78], P = 0.028) but not men (1.70 higher T score [SE 1.74], P = 0.33). The relationships between cerebrovascular function and specific cognitive domains followed a similar pattern, with significant associations present among women but not men.

CONCLUSIONS

Women with well-controlled HIV may be more vulnerable to the effect of cerebrovascular injury on cognitive health than men. Studies evaluating strategies to protect against cognitive impairment in people living with HIV should include adequate representation of women and stratification of analyses by sex.

Comparative efficacy and acceptability of non-pharmacological interventions for depression in people living with HIV: A systematic review and network meta-analysis

BACKGROUND

Treatment for depression in people living with HIV has increasingly turned to non-pharmacological treatments due to the adverse reactions of pharmacotherapy. However, it remains unclear which non-pharmacological treatment is the most effective and acceptable for depression in people living with HIV.

OBJECTIVE

To compare and rank the efficacy and acceptability of different non-pharmacological treatments for depression in people living with HIV.

DESIGN

A systematic review and Bayesian network meta-analysis.

METHODS

We systematically searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, PsycArticles, CINAHL, ProQuest, OpenGrey, and international trial registers for published and unpublished studies from their inception to September 1, 2022, and searched key conference proceedings from January 1, 2020, to September 25, 2022. We searched for randomized controlled trials of any non-pharmacological treatments for depression in adults living with HIV (≥18 years old). Primary outcomes were efficacy (mean change scores in depression) and acceptability (all-cause discontinuation). We used a random-effects network meta-analysis model to synthesize all available evidence. The methodological quality of the included studies was assessed using the Cochrane Collaboration Risk of Bias Tool. We registered this study in PROSPERO, number CRD42021244230.

RESULTS

A total of 53 randomized controlled trials were included in this network meta-analysis involving seven non-pharmacological treatments for depression in people living with HIV. For efficacy, mind-body therapy, interpersonal psychotherapy, cognitive-behavioral therapy, supportive therapy, and education were significantly more effective than most control conditions (standardized mean differences ranged from -0.96 to -0.36). Rankings probabilities indicated that mind-body therapy (79%), interpersonal psychotherapy (71%), cognitive-behavioral therapy (62%), supportive therapy (57%), and education (57%) might be the top five most significantly effective treatments for depression in people living with HIV, in that order. For acceptability, only supportive therapy and interpersonal psychotherapy were significantly less acceptable than most control conditions (odds ratios ranged from 1.92 to 3.43). Rankings probabilities indicated that education might be the most acceptable treatment for people living with HIV (66%), while supportive therapy (26%) and interpersonal psychotherapy (10%) might rank the worst. The GRADE assessment results suggested that most results were rated as "moderate" to "very low" for the confidence of evidence.

CONCLUSIONS

Our study confirmed the efficacy and acceptability of several non-pharmacological treatments for depression in people living with HIV. These results should inform future guidelines and clinical decisions for depression treatment in people living with HIV.

Effectiveness of an integrated multilevel early child development intervention on caregiver knowledge and behavior: a quasi-experimental evaluation of the Malezi program in Tanzania

BACKGROUND

The quality of caregiving and the parent-child relationship is critical for early child development (ECD) and has been shown to be modifiable. This study evaluated an ECD project in Tanzania, assessing the effectiveness of radio messaging (RM) alone and a combined radio messaging/video job aids/ECD (RMV-ECD) intervention.

METHODS

This two-arm pre-post evaluation study enrolled a cohort of caregivers of children 0-24 months in four districts of Tabora region, following them for 9 months. ECD radio messages were broadcast on popular stations at least 10 times/day reaching all study districts. In two districts, community health workers (CHW), trained in UNICEF's Care for Child Development package, used ECD videos in home- and facility-based sessions with caregivers. We used McNemar's testing (pre-post pairs) within intervention group to describe how the intervention was associated with change in five outcomes: ECD knowledge, early stimulation, father engagement, responsive care, and environment safety. Logistic regression was used to describe the relative benefits of the combined intervention package (RMV-ECD) compared to radio messaging (RM).

RESULTS

In the RMV-ECD arm, all outcomes at endline except environment safety significantly improved after the intervention with the largest change seen in ECD knowledge (35.8% increase, p < .0001) and the smallest in father engagement (6.7%, p = .015). In the RM arm, ECD knowledge (5.7%, p = .031) and environment safety (18.1%, p = <.0001) improved. High measures of parenting stress were associated with lower likelihood of having good ECD knowledge (AOR 0.50, 95%CI: 0.35, 0.71), father engagement (AOR 0.72, 95%CI: 0.52, 0.99) and responsive care (AOR 0.31, 95%CI: 0.18, 0.54).

CONCLUSIONS

An intervention that includes mass media, educational video content and CHWs who counsel caregivers in their homes and health facilities was associated with significant improvements in ECD parenting knowledge and behaviors but a relationship with responsive care could not be established. The less costly mass media-only intervention was associated with improved parenting knowledge and household environment safety. Parenting interventions targeting young children could be improved by incorporating more messaging and caregiver coaching in managing parental stress.

TRIAL REGISTRATION

NCT05244161 (17/02/2022); retrospectively registered with the US National Institutes of Health ClinicalTrials.gov.

Demonstration project of a lay counselor delivered trans-diagnostic mental health intervention for newly diagnosed HIV patients in Mozambique

ABSTRACTCommon mental disorders (CMDs) are associated with poor HIV outcomes in low- and middle-income countries. The present study implemented a psychological therapy delivered in routine HIV care and examined its effects on HIV outcomes in Mozambique. The Common Elements Treatment Approach (CETA) was integrated into routine HIV care in Sofala, Mozambique for all newly-diagnosed HIV+ patients with CMD symptoms. HIV treatment initiation and retention were compared to overall facility averages (those enrolled in CETA + those not enrolled). Of 250 patients screened, 59% (n = 148 met the criteria for CETA enrollment, and 92.6 (n = 137) enrolled in CETA. After four CETA visits, CMD symptoms decreased >50% and suicidal ideation decreased 100%. Patients enrolling in CETA had an antiretroviral therapy initiation rate of 97.1%, one-month retention of 69.2%, and three-month retention of 82.4%. Patients in the comparison group had one-month retention of 66.0% and three-month retention of 68.0%. CETA may be a promising approach to reduce symptoms of CMDs and improve HIV care cascade outcomes in areas with high HIV prevalence.

Long-Term Effect of Group Support Psychotherapy on Depression and HIV Treatment Outcomes: Secondary Analysis of a Cluster Randomized Trial in Uganda

OBJECTIVE

We aimed to determine the effect of group support psychotherapy (GSP) compared with group HIV education (GHE) on depression and HIV treatment outcomes 24 months after treatment. We further aimed to investigate the mediating role of depression and antiretroviral therapy (ART) adherence in the relationship between GSP and viral load suppression.

METHODS

Thirty HIV clinics across three districts were randomly assigned to deliver either GSP or GHE for depression. Depression and optimal (≥95%) ART adherence was assessed at baseline and 6, 12, 18, and 24 months after treatment. Viral load was drawn from the medical charts at baseline and 12 and 24 months after treatment. Multilevel mixed-effects regression models and generalized structural equation modeling were used to estimate 24-month outcomes and mediation effects.

RESULTS

Participants ( N = 1140) were enrolled from HIV clinics offering either GSP ( n = 578 [51%]) or GHE ( n = 562 [49%]). Fewer GSP than GHE participants met the criteria for depression at 24 months after treatment (1% versus 25%; adjusted odds ratio [aOR] = 0.002, 95% confidence interval [CI] = 0.0002-0.018). More GSP than GHE participants reported optimal (≥95%) ART adherence (96% versus 88%; aOR = 20.88, 95% CI = 5.78-75.33) and improved viral suppression (96% versus 88%; aOR = 3.38, 95% CI = 1.02-11.02). The indirect effects of GSP through sequential reduction in depression and improvement in ART adherence at 12 months may partially explain the higher viral suppression rates at 24 months in GSP than GHE groups.

CONCLUSION

In settings where the HIV epidemic persists, depression treatment with GSP may be critical for optimal HIV treatment outcomes.Trial Registration: The Pan African Clinical Trials Registry, number PACTR201608001738234.

Patient-Reported Treatment Satisfaction and Quality of Life Among People Living with HIV Following the Introduction of Dolutegravir-Based ART Regimens in Ukraine

In 2017, the government of Ukraine initiated its ART Optimization Initiative, revising its national antiretroviral therapy (ART) guidelines and embracing Dolutegravir (DTG) as a backbone of first-line ART regimens. A cross-sectional survey of 464 ART patients from 22 large ART clinics was carried out in mid-2019. The survey assessed patient-reported outcomes (PROS) including treatment satisfaction, physical health, mental health, depression, side effects of ART, and adherence. The associations between ART regimen and PROs were assessed using bivariable and multivariable generalized estimating equations (GEE) models. More than half (55.6%) of the patients were satisfied with their current ART regimen. Less than a half (45.3%) considered their physical health as good while only 36.9% rated their mental health as good, 21.3% reported moderate or severe depression, 82.3% reported no side effect in the past 4 weeks, and 44.4% reported not missing ART medication in the past month. In adjusted analysis, patients starting ART with DTG had higher treatment satisfaction compared to people continuing LPV-based regimens (aOR = 0.49, 95% confidence interval: 0.22-0.90). Also in adjusted analyses, unemployment, low income, and history of injection drug use were associated with unfavorable PROs. While the results indicate modestly favorable effects of ART Optimization, there is clearly a need for complementary interventions to improve PROs among disadvantaged ART patients in Ukraine.

Correlates and cascade of HIV care in patients with psychiatric disorders in the Eastern Cape province, South Africa

Background

The cascade of human immunodeficiency virus (HIV) care in patients with psychiatric disorders is poorly understood.

Aim

This study determined the prevalence of HIV and described its cascade of care among patients with psychiatric disorders in the Eastern Cape province, South Africa. The study also examined the correlates of HIV comorbidity with psychiatric disorders in the cohort.

Methods

In this cross-sectional study, a total of 368 individuals attending the Psychiatric Outpatients’ Department of Cecilia Makiwane Hospital in Eastern Cape were interviewed with a structured questionnaire. Relevant items on demographics and clinical information were extracted from the medical records. Virologic suppression was defined as viral load < 1000 RNA copies/mL.

Results

The HIV prevalence after the intervention was 18.8% and a significant proportion of participants already knew their status (n = 320; 87.0%). Linkage to care and antiretroviral therapy initiation occurred in 61 participants, of those diagnosed with HIV (88.4%), with 84.1% being eligible for viral load monitoring (n = 58) and 53.4% having achieved virologic suppression. Being female (AOR = 5.48; 95% CI 2.61–11.51) and black (adjusted odds ratio [AOR] = 3.85; 95% confidence interval [CI] 1.06–14.03) were independent predictors of HIV comorbidity in individuals living with psychiatric disorders.

Conclusion

This study found a moderately high prevalence (close to 19%) of HIV in individuals with psychiatric disorders, with a significant correlation with being female and being black people. This study also found a significant gap in the linkage to antiretroviral therapy (ART) initiation and a low rate of virologic suppression of 53.4%. Clinicians, therefore, should monitor and provide interventions for patients with concomitant HIV infection along this cascade of care.

Trends and Clinical Characteristics of HIV and Cerebrovascular Disease in Low- and Middle-Income Countries (LMICs) Between 1990 and 2021

PURPOSE OF THE REVIEW

To describe trends and clinical characteristics of HIV and cerebrovascular disease between 1990 and 2021 in LMICs and identify the gaps in our understanding.

RECENT FINDINGS

In the era of antiretroviral therapy (ART), people living with HIV (PLWH) live longer and risk excess cerebrovascular events due to ageing and HIV-driven factors. Despite the highest burden of HIV infection in low-to-middle income countries, there is underreporting in the literature of cerebrovascular events in this population. We systematically reviewed published literature for primary clinical studies in adult PLWH and cerebrovascular disease in LMICs. The clinical phenotype of cerebrovascular disease among PLWH over the last three decades in LMICs has evolved and transitioned to an older group with overlapping cerebrovascular risk factors. There is an important need to increase research in this population and standardise reporting to facilitate understanding, guide development of appropriate interventions, and evaluate their impact.

Worldwide Occurrence of HIV-Associated Neurocognitive Disorders and Its Associated Factors: A Systematic Review and Meta-Analysis

BACKGROUND

HIV-associated neurocognitive disorders are common in people living with HIV/AIDS and affect the adherence of patients to prescriptions, activities of daily living, and quality of life of patients. However, there is a lack of summative evidence in the area. The present meta-analysis was therefore addressing this gap.

METHODS

We did our electronic search in Psych-Info, EMBASE, Scopus, and PubMed. The retrieved articles were stored with the endnote reference manager and data was extracted using Meta-XL version 5.3. The quality of studies was evaluated with the modified Newcastle-Ottawa Scale (NOS). A random-effect model and STATA-16 were used to compute the average estimate of HAND. Heterogeneity was weighed with I² statistics. A sensitivity analysis and subgroup analysis were employed. The existence/nonexistence of a publication bias was checked with the Eggers test of publication bias.

RESULTS

The average prevalence of HAND was 50.41% (95% CI: 45.56, 55.26). The average estimate of HAND in Europe was found to be 50.015% whereas in Africa, Asia, and the United States of America (USA) it was 49.566, 52.032, and 50.407% respectively. The prevalence of HAND in studies that used the HIV Dementia Scale (IHDS) was 36.883% and 59.956% at cutoff points of IHDS <9.5 and IHDS <10 respectively. Besides, the estimated average of HAND with the global dementia scale (GDS) was 40.766%. The prevalence of HAND in cross-sectional, cohort, and case-control studies was 49.52, 54.087, and 44.45% in that order. Socio-demographic variables; low level of education and older age, clinical and HIV related variables; the advanced stage of the illness and CD4 count of 500 cells/dl or less and psychological variables such as comorbidity of depression increases the risk of HAND.

CONCLUSION

The prevalence of HIV-associated neurocognitive disorders was about 50.41%. Low level of education and older age, clinical and HIV related variables such as the advanced stage of the illness and CD4 count of 500 cells/dl or less, and comorbidity of depression were associated with HIV associated neurocognitive disorders. Public health interventions for HIV patients should target these essential problems.

An evaluation of a combined psychological and parenting intervention for HIV-positive women depressed in the perinatal period, to enhance child development and reduce maternal depression: study protocol for the Insika Yomama cluster randomised controlled trial

BACKGROUND

The combination of poverty, HIV and depression in the perinatal period represents a major public health challenge in many Southern African countries. In some areas, up to a third of HIV-positive women experience perinatal depression. Perinatal depression is associated with negative effects on parenting and key domains of child development including cognitive, behavioural and growth, especially in socio-economically disadvantaged communities. Several studies have documented the benefits of psychological interventions for perinatal depression in low- and middle-income countries, but none have evaluated an integrated psychological and parenting intervention for HIV-positive women using task-sharing. This randomised controlled trial aims to evaluate the effect of a home-based intervention, combining a psychological treatment for depression and a parenting programme for perinatally depressed HIV-positive women.

METHODS

This study is a cluster randomised controlled trial, consisting of 48-60 geospatial clusters. A total of 528 pregnant HIV-positive women aged ≥ 16 years who meet the criteria for depression on the Edinburgh Postnatal Depression Scale (EPDS, score ≥ 9)) are recruited from antenatal clinics in rural KwaZulu-Natal, South Africa. The geospatial clusters are randomised on an allocation ratio of 1:1 to either the intervention or Enhanced Standard of Care (ESoC). The intervention group receives 10 home-based counselling sessions by a lay counsellor (4 antenatal and 6 postnatal sessions) and a booster session at 16 months. The intervention combines behavioural activation for depression with a parenting programme, adapted from the UNICEF/WHO Care for Child Development programme. The ESoC group receives two antenatal and two postnatal counselling support and advice telephone calls. In addition, measures have been taken to enhance the routine standard of care. The co-primary outcomes are child cognitive development at 24 months assessed on the cognitive subscale of the Bayley Scales of Infant Development-Third Edition and maternal depression at 12 months measured by the EPDS.

ANALYSIS

The primary analysis will be a modified intention-to-treat analysis. The primary outcomes will be analysed using mixed-effects linear regression.

DISCUSSION

If this treatment is successful, policymakers could use this model of mental healthcare delivered by lay counsellors within HIV treatment programmes to provide more comprehensive services for families affected by HIV.

TRIAL REGISTRATION

ISRCTN registry # 11284870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).

Interventions to address the mental health of adolescents and young adults living with or affected by HIV: state of the evidence

INTRODUCTION

Adolescents and young adults (AYA) remain vulnerable to HIV-infection and significant co-morbid mental health challenges that are barriers to treatment and prevention efforts. Globally millions of AYA are living with HIV (AYALH) and/or have been affected by HIV in their families (AYAAH), with studies highlighting the need for mental health programmes. With no current guidelines for delivering mental health interventions for AYALH or AYAAH, a scoping review was undertaken to explore current evidence-based mental health interventions for AYALH and AYAAH to inform future work.

METHODS

The review, targeting work between 2014 and 2020, initially included studies of evidence-based mental health interventions for AYALH and AYAAH, ages 10 to 24 years, that used traditional mental health treatments. Given the few studies identified, we expanded our search to include psychosocial interventions that had mental health study outcomes.

RESULTS AND DISCUSSION

We identified 13 studies, seven focused on AYALH, five on AYAAH, and one on both. Most studies took place in sub-Saharan Africa. Depression was targeted in eight studies with the remainder focused on a range of emotional and behavioural symptoms. Few studies used evidence-based approaches such as Cognitive Behaviour Therapy; psychosocial approaches included mental health treatments, group-based and family strengthening interventions, economic empowerment combined with family strengthening, group-based mindfulness and community interventions. Eleven studies were randomized control trials with four pilot studies. There was variation in sample size, treatment delivery mode (individual focus, group-based, family focus), and measures of effectiveness across studies. Most used trained lay counsellors as facilitators, with few using trained mental health professionals. Eleven studies reported positive intervention effects on mental health.

CONCLUSIONS

Despite the need for mental health interventions for AYALH and AYAAH, we know surprisingly little about mental health treatment for this vulnerable population. There are some promising approaches, but more work is needed to identify evidence-based approaches and corresponding mechanisms of change. Given limited resources, integrating mental health treatment into healthcare settings and using digital health approaches may support more standardized and scalable treatments. Greater emphasis on implementation science frameworks is needed to create sustainable mental health treatment for AYALH and AYAAH globally.

The Association between HIV-Stigma and Depressive Symptoms among People Living with HIV/AIDS: A Systematic Review of Studies Conducted in South Africa

BACKGROUND

People living with HIV/AIDS (PLWHA) are at increased risk of stigma and mental illness, and this appears to be a particular issue in South Africa, which is home to 19% of the world's HIV-positive population. This paper aims to systematically review the literature investigating the relationship between HIV-stigma and depressive symptoms among PLWHA in South Africa.

METHODS

A keyword search of four bibliographic databases (CINAHL, Ovid MEDLINE, PsycINFO, and Web of Science) and two grey literature websites was conducted. The quality of eligible studies was assessed using established criteria.

RESULTS

Fourteen quantitative studies were included in the review. PLWHA in South Africa experience high levels of HIV-stigma and depressive symptoms. All forms of stigma were found to be associated with depressive symptoms amongst PLWHA. Prospective findings were mixed, with one study finding that stigma did not predict depressive symptoms over 36 months, and another that depressive symptoms predicted stigma 12 months later, suggesting a potentially bidirectional relationship. Females and young adults may be particularly vulnerable to HIV-stigma and its negative psychological effects. Some support was found for the moderating role of social support in the relationship between stigma and depressive symptoms across different sub-populations.

LIMITATIONS

Few studies conducted prospective analyses or tested mediation/moderation.

CONCLUSIONS

Despite limitations, this study highlights the importance of understanding the mechanisms underlying HIV-stigma across different sub-populations in South Africa. This may lead to more effective and context-specific interventions to combat adverse mental health outcomes.

Examining common mental health disorders in people living with HIV on methadone maintenance therapy in Hanoi, Vietnam

BACKGROUND

Injection drug use drives HIV transmission in Southeast Asia, where around a quarter of users are living with HIV. Vietnam developed Methadone Maintenance Therapy (MMT) programs to reduce unsafe drug abuse. Common mental health disorders (CMD), including depression, anxiety and post-traumatic stress disorder (PTSD), can worsen MMT outcomes and are highly prevalent among people living with HIV (PLH). We aimed to characterize HIV and CMD among MMT patients and assess the impact of HIV and CMD on MMT engagement outcomes in Hanoi, Vietnam.

METHODS

This cross-sectional study was conducted at an urban MMT clinic in Hanoi. Participants were screened for CMD with the relevant sections of the Mini International Neuropsychiatric Interview (MINI). Tabular comparisons and regression models were used to understand the association of HIV and CMD with substance use and methadone compliance.

RESULTS

Of the 400 MMT participants, 22% were living with HIV, 11% a CMD, 27% reported injection drug use, and 27% reported methadone noncompliance. Around 17% of those with HIV also had a CMD. Reporting non injection and injection drug use were each higher among those with CMD regardless of HIV status. In addition, reporting any drug use was much higher among those with both HIV and CMD than among those with neither (73% vs 31%, p value 0.001). While methadone noncompliance was lower among PLH than among those without HIV (16.3% vs 30.1%, p value 0.010), noncompliance was higher among those with CMD than among those without (40.5% vs 25.6%, p value 0.045). Among those without HIV, noncompliance was higher among those with CMD than among those without, but among those with HIV, the opposite relationship was observed.

CONCLUSION

There is complex overlap between substance use and methadone noncompliance among MMT patients living with HIV, CMD or both. In this population, we found a high prevalence of CMD and substance use among PLH, and a high prevalence of substance use and methadone noncompliance among those with CMD. Prioritizing provision of mental health care services to MMT patients living with HIV can help improve engagement with substance use disorder treatment and reduce the risk of HIV transmission.

HIV-1 and drug abuse comorbidity: Lessons learned from the animal models of NeuroHIV

Various research studies that have investigated the association between HIV infection and addiction underpin the role of various drugs of abuse in impairing immunological and non-immunological pathways of the host system, ultimately leading to augmentation of HIV infection and disease progression. These studies have included both in vitro and in vivo animal models wherein investigators have assessed the effects of various drugs on several disease parameters to decipher the impact of drugs on both HIV infection and progression of HIV-associated neurocognitive disorders (HAND). However, given the inherent limitations in the existing animal models of HAND, these investigations only recapitulated specific aspects of the disease but not the complex human syndrome. Despite the inability of HIV to infect rodents over the last 30 years, multiple strategies have been employed to develop several rodent models of HAND. While none of these models can accurately mimic the overall pathophysiology of HAND, they serve the purpose of modeling some unique aspects of HAND. This review provides an overview of various animal models used in the field and a careful evaluation of methodological strengths and limitations inherent in both the model systems and study designs to understand better how the various animal models complement one another.

Common mental disorders and intimate partner violence against pregnant women living with HIV in Cameroon: a cross-sectional analysis

BACKGROUND

Women living with HIV are at increased risk of poor mental health and intimate partner violence (IPV). Mental health disorders have been consistently associated with suboptimal HIV-related outcomes. Little is known about the prevalence or correlates of mental health disorders among pregnant women living with HIV in sub-Saharan Africa.

METHODS

This study assessed the prevalence of probable common mental disorders (CMD), i.e., depressive or anxiety disorders, and the relationship between probable CMD and recent IPV among pregnant women living with HIV in Cameroon. The sample included 230 pregnant women living with HIV aged > 18 enrolled in care at 10 HIV clinics in Cameroon. Probable CMD was assessed with the WHO Self Reporting Questionnaire (SRQ-20). Multivariable logistic regression was conducted to assess the relationship between IPV and probable CMD.

RESULTS

Almost half (42%) of participants had probable CMD using a 7/8 cut-off of the SRQ-20. Emotional, physical, and sexual IPV were reported by 44, 37, and 31% of respondents, respectively. In multivariable regression analyses, all forms of IPV assessed were significantly associated with greater odds of probable CMD.

CONCLUSIONS

Pregnant women living with HIV in Cameroon had a high prevalence of probable CMD and IPV. Screening and services to address IPV and mental health are urgently needed for this population. Integrated interventions to both prevent and screen and address IPV and probable CMD should be developed, implemented, and evaluated.

The syndemic effects of mental ill health, household hunger, and intimate partner violence on adherence to antiretroviral therapy among pregnant women living with HIV in Yaoundé, Cameroon

Background

This research advances understanding of interrelationships among three barriers to adherence to antiretroviral therapy (ART) among pregnant women living with HIV (WLWH) in Cameroon: probable common mental disorders (CMD), intimate partner violence (IPV), and hunger.

Methods

The sample included 220 pregnant WLWH in Cameroon. Multivariable modified Poisson regression was conducted to assess the relationship between IPV, hunger, and CMD on ART adherence.

Results

Almost half (44%) of participants recently missed/mistimed an ART dose. Probable CMD was associated with greater risk of missed/mistimed ART dose (aRR 1.5 [95% CI 1.1, 1.9]). Hunger was associated with greater risk of missed/mistimed ART dose among those who reported IPV (aRR 1.9 [95% CI 1.2, 2.8]), but not among those who did not (aRR 0.8 [95% CI 0.2, 2.3]).

Conclusion

Suboptimal ART adherence, CMD, and IPV were common among pregnant WLWH in Cameroon. Pregnant WLWH experiencing IPV and hunger may be especially vulnerable to suboptimal ART adherence.

A Cascade of Interventions to Promote Adherence to Antiretroviral Therapy in African Countries

Purpose of Review

We reviewed interventions to improve uptake and adherence to antiretroviral therapy (ART) in African countries in the Treat All era.

Recent Findings

ART initiation can be improved by facilitated rapid receipt of first prescription, including community-based linkage and point-of-care strategies, integration of HIV care into antenatal care and peer support for adolescents. For people living with HIV (PLHIV) on ART, scheduled SMS reminders, ongoing intensive counselling for those with viral non-suppression and economic incentives for the most deprived show promise. Adherence clubs should be promoted, being no less effective than facility-based care for stable patients. Tracing those lost to follow-up should be targeted to those who can be seen face-to-face by a peer worker.

Summary

Investment is needed to promote linkage to initiating ART and for differentiated approaches to counselling for youth and for those with identified suboptimal adherence. More evidence from within Africa is needed on cost-effective strategies to identify and support PLHIV at an increased risk of non-adherence across the treatment cascade.

Electronic supplementary material

The online version of this article (10.1007/s11904-020-00511-4) contains supplementary material, which is available to authorized users.

COVID-19 AND STIGMATISATION OF HEALTHCARE PROVIDERS

The aim: this study presents a Coronavirus Stigma Scale for Healthcare Providers that indicates the social stigmatisation rate and severity toward healthcare providers to a certain extent. This paper aims at raising awareness on the stigmatisation of healthcare providers who sacrifice their own lives for patients diagnosed or are at risk of being infected with COVID-19. Methods: the study uses a 12-item 5-point Likert-type Coronavirus Stigma Scale for Healthcare Providers, which was constructed based on the previously shortened and modified HIV Stigma Scale. The scale was distributed online to healthcare providers, and all the results obtained were then saved to an Excel file. Correlations were determined by using ANOVA and the independent t-test. Percentages, averages, figures and rates were calculated with SPSS. Results: the population of the study comprised 136 participants in total; 40 male and 96 female. Reliability and validity studies were conducted using Cronbach’s alpha and factor analysis. The stigmatisation rate toward healthcare providers was found to be significantly high, and the stigmatisation level was found to increase significantly with increasing age (p<0.05). Conclusions: the mistreatment of stigmatised healthcare providers during a pandemic where the need for them is elevated results in adverse outcomes; therefore, anti-stigma programmes need to be developed. It would be wise to find solutions such as acknowledging the stigma and introducing anti-stigma programmes.

Universal HIV Testing and Treatment (UTT) Integrated with Chronic Disease Screening and Treatment: the SEARCH study

PURPOSE OF REVIEW

The growing burden of untreated chronic disease among persons with HIV (PWH) threatens to reverse heath gains from ART expansion. Universal test and treat (UTT)'s population-based approach provides opportunity to jointly identify and treat HIV and other chronic diseases. This review's purpose is to describe SEARCH UTT study's integrated disease strategy and related approaches in Sub-Saharan Africa.

RECENT FINDINGS

In SEARCH, 97% of adults were HIV tested, 85% were screened for hypertension, and 79% for diabetes at health fairs after 2 years, for an additional $1.16/person. After 3 years, population-level hypertension control was 26% higher in intervention versus control communities. Other mobile/home-based multi-disease screening approaches have proven successful, but data on multi-disease care delivery are extremely limited and show little effect on clinical outcomes. Integration of chronic disease into HIV in the UTT era is feasible and can achieve population level effects; however, optimization and implementation remain a huge unmet need.

Clinical and Obstetric Risk Factors for Postnatal Depression in HIV Positive Women: A Cross Sectional Study in Health Facilities in Rural KwaZulu-Natal

Postnatal depression (PND) remains underdiagnosed and undertreated in different socio-economic backgrounds in South Africa. This study determined the prevalence of and clinical and obstetric risk factors for PND symptoms among HIV positive women in health facilities in a rural health district in South Africa. The Edinburgh Postnatal Depression Scale was used to measure PND from 386 women who had delivered a live infant. More than half (58.5%) tested HIV positive during the current pregnancy. The prevalence of PND symptoms was 42.5%. Logistic regression analysis yielded significant associations between clinical and obstetric variables of pre-term baby (p-value < 0.01), baby health status p-value < 0.01), baby hospitalization, (p-value < 0.01), and knowing the baby’s HIV status (p-value = 0.047). Maternal variables associated with PND were level of education (p-value < 0.01), monthly income (p-value < 0.01), and source of income (p-value = 0.05). At multivariate analysis, none of the clinical and obstetrical risk factors were independently associated with the PND. The high prevalence of PND symptoms underscore the need to integrate routine screening for PND in prevention of mother to child transmission of HIV programmes to enable early diagnosing and treatment of PND.

Prevalence and factors associated with severe depressive symptoms in older west African people living with HIV

BACKGROUND

Depression is one of the most common psychiatric disorders in people living with HIV (PLHIV). Depression has a negative impact on both mental and physical health and is mainly associated with suboptimal HIV treatment outcomes. To encourage successful aging and the achievement of the 3 × 90 objectives in older PLHIV, the psychological domain must not be neglected. In this context and as data are scarce in West Africa, this study aimed to evaluate the prevalence and the factors associated with severe depressive symptoms in older PLHIV living in this region of the world.

METHODS

Data from PLHIV aged ≥50 years and on ART since ≥6 months were collected in three clinics (two in Côte d'Ivoire, one in Senegal) participating in the West Africa International epidemiological Databases to Evaluate AIDS (IeDEA) collaboration. The severity of depressive symptoms was measured using the Center for Epidemiological Studies Depression scale (CES-D), and associated factors were identified using logistic regressions.

RESULTS

The median age of the 334 PLHIV included in the study was 56.7 (53.5-61.1), 57.8% were female, and 87.1% had an undetectable viral load. The prevalence of severe depressive symptoms was 17.9% [95% Confidence Interval (95% CI): 13.8-22.0]. PLHIV with severe depressive symptoms were more likely to be unemployed (adjusted Odd Ratio (aOR) = 2.8; 95% CI: 1.4-5.7), and to be current or former tobacco smokers (aOR = 2.6; 95% CI: 1.3-5.4) but were less likely to be overweight or obese (aOR = 0.4; 95% CI: 0.2-0.8).

CONCLUSIONS

The prevalence of severe depressive symptoms is high among older PLHIV living in West Africa. Unemployed PLHIV and tobacco smokers should be seen as vulnerable and in need of additional support. Further studies are needed to describe in more details the reality of the aging experience for PLHIV living in SSA. The integration of screening and management of depression in the standard of care of PLHIV is crucial.

Exploring patterns and predictors of suicidal ideation among pregnant and postpartum women living with HIV in Kilimanjaro, Tanzania

OBJECTIVE

Pregnant and postpartum women living with HIV face disproportionate risk of depression and suicide, particularly in low-income and middle-income countries. This study examined patterns and predictors of suicidal ideation among women living with HIV in antenatal care in Kilimanjaro, Tanzania.

DESIGN

We conducted a longitudinal cohort study of 200 pregnant women living with HIV, with surveys conducted during pregnancy and 6 months postpartum.

METHODS

Pregnant women were recruited during HIV and antenatal care visits at nine clinics. A structured questionnaire was verbally administered in Kiswahili by a trained study nurse. We used simple frequencies and t-tests to measure patterns of suicidal ideation and logistic regression to assess factors associated with suicidal ideation.

RESULTS

Suicidal ideation was endorsed by 12.8% of women during pregnancy and decreased significantly to 3.9% by 6 months postpartum. Ideation was not significantly greater among participants newly diagnosed with HIV. In univariable analyses, suicidal ideation was associated with depression, anxiety, HIV stigma, single relationship status, unknown HIV status of the father of the baby, negative attitudes about antiretroviral medication, and low social support. In the multivariable model, women experiencing anxiety and HIV stigma were significantly more likely to endorse suicidal ideation during pregnancy.

CONCLUSION

Suicidal ideation and associated feelings of hopelessness are a critical challenge in antenatal care among women living with HIV, with important implications for quality of life, care engagement, and survival. To better support patients, targeted approaches to address anxiety, depression, stigma, and hopelessness must be prioritized, including crisis support for suicide prevention.

"Now We Are Told That We Can Mix": Messages and Beliefs Around Simultaneous Use of Alcohol and ART

South Africa (SA) has the most people living with HIV/AIDS (PLWH) globally and prevalent alcohol use. Beliefs that mixing alcohol and antiretroviral therapy (ART) can lead to adverse reactions may promote ART nonadherence. Healthcare providers (n = 11) and patients (n = 19) recruited from primary HIV and substance use care in SA described their messages, beliefs, and behaviors around simultaneous use of alcohol and ART. Transcripts were analyzed using thematic analysis: (1) most providers indicated a message shift to reflect harm reduction principles: PLWH should manage alcohol use but not let it interfere with taking ART; however, (2) patients recalled conflicting messages from their providers and some displayed interactive toxicity beliefs and behaviors. Despite progress demonstrated by 2016 national adherence guidelines and shifted provider messaging, interactive toxicity beliefs remain a barrier to ART adherence. Results have implications for the adaptation of adherence counseling to minimize the impact of alcohol use on HIV treatment.

Social and Economic Equity and Family Cohesion as Potential Protective Factors from Depression Among Adolescents Living with HIV in Uganda

Adolescents living with HIV in Uganda are impacted by poverty and face a number of health and social challenges including access to medication, health complications, and social stigma. These stressors have been linked to depression, which can lead to lower HIV treatment adherence. This study seeks to determine how social and economic equity, family cohesion, and social supports may be related to depression among adolescents living with HIV. We used baseline data from the Suubi + Adherence study, a 5-year longitudinal randomized controlled trial among adolescents living with HIV in southwestern Uganda (n = 675; ages 10-16 years). Hierarchical logistic regression models were conducted separately among in-school adolescents and out-of-school adolescents to assess the hypothesized associations between economic and social equity, social support, and depression. About half of the participants meet the criteria for depression. Adolescents with depression were found to have fewer economic and social supports. Our findings indicate that social and economic equity [odds ratio (OR) = 0.85, 95% confidence interval (CI) 0.74, 0.99], family cohesion (OR = 0.94, 95% CI 0.91-0.96), and social support from friends (OR = 0.95, 95% CI 0.91-0.998) are associated with depression for in-school HIV infected adolescents and could be protective factors. The results of this study suggest that social and economic equity may play a protective role against depression and other poor mental health outcomes. Potential interventions for adolescents living with HIV should consider these social and familial factors as they may be protective of depression in this population.

Knowledge of health practitioners regarding mental health integration into human immunodeficiency virus management into primary healthcare level

Background

Mental disorders are common among people living with human immunodeficiency virus (HIV). Human immunodeficiency virus infection is associated with neurological complications, which may negatively affect antiretroviral treatment, leading to virologic as well as immunologic failure. The integration of mental healthcare services into HIV services at a primary healthcare level is vital, as this is the first contact point for most patients accessing healthcare services.

Objectives

The aim of this study was to determine the knowledge of healthcare professionals about the integration of mental healthcare services into HIV services at a primary healthcare level.

Method

This study was a quantitative descriptive study, designed to determine the knowledge of healthcare professionals towards integrating mental healthcare services into routine services at primary healthcare centres. The purposive sampling method was employed to select the 200 healthcare professionals who participated in this study.

Results

The majority of the healthcare professionals (91%) who participated in this study had limited knowledge regarding the integration of mental healthcare services into HIV services at a primary healthcare level. Very few (9%, n = 18) had adequate knowledge about the integration of mental healthcare services into HIV services.

Conclusion

Most of the participants had limited knowledge about the subject matter. This, therefore, shows that all stakeholders involved need to implement initiatives to address this knowledge gap.

Sociodemographic and psychosocial predictors of longitudinal antiretroviral therapy (ART) adherence among first-time ART initiators in Cape Town, South Africa

First-time antiretroviral therapy (ART) initiators may be more vulnerable to poor ART adherence because they may be coping with a new HIV diagnosis, facing logistical challenges to accessing and adhering to ART for the first time, and have not yet developed support networks or the skills to support long-term adherence. We recruited 324 participants in two HIV clinics near Cape Town, South Africa. Sociodemographic/psychosocial factors were measured at baseline and self-reported adherence at the 6 month follow-up. We conducted multivariable regression to determine which baseline factors were associated with 6-month adherence. A better patient-clinic relationship score (OR: 1.08 [95% CI: 1.05-1.11]) was associated with higher adherence. A drug use problem (0.51 [0.29-0.87]), higher social isolation (0.93 [0.87-0.99]), and greater number of years living with HIV before initiating ART (0.92 [0.86-1.00]) were associated with adherence levels below 90%. Patient-clinic relationships and social support are key psycho-social factors in early adherence behavior. Reducing drug use problems through targeted screening and early intervention may improve ART adherence.

HIV-associated neurocognitive disorders at Moi teaching and referral hospital, Eldoret, Kenya

Background

Human Immunodeficiency Virus (HIV) infection causes a myriad of neurological complications including cognitive deficits referred to as HIV-Associated Neurocognitive Disorders (HAND). With the introduction of combination antiretroviral therapy, there has been an epidemiological shift in cognitive disorders with a decline in the more severe HIV-Associated Dementia (HAD) to an increase in the less severe HAND: Asymptomatic Neurocognitive Impairment (ANI) and HIV-associated Mild Neurocognitive Disorder (MND). Central Nervous System (CNS) involvement in HIV interferes with cognitively demanding activities of daily living and hence a worse quality of life. Early diagnosis is delayed until symptoms are overt.

Methods

We conducted a cross sectional analytical study of HIV infected persons on antiretroviral therapy attending HIV clinic. A systematic random sampling was done to select 360 patients. An interviewer administered structured questionnaire was used to collect socio-demographic data while the CD4 count and viral load were retrieved from the Academic Model Providing Access to Healthcare (AMPATH) database. Pearson’s Chi Square test was used to compare proportions while independent sample t- test was used to compare continuous variables between the patients diagnosed with HAND and those without HAND. Logistic regression model was used to assess the factors associated with HAND.

Results

The mean age of the study participants was 40.2 years. The overall prevalence of HAND was (81.1%) N = 292. Mild HAND (ANI and MND) was present (78.6%) N = 283, Severe HAND (HAD) (2.5%) N = 9. The factors associated with HAND were older age OR: 1.06 (95% CI: 1.03, 1.10), male gender OR: 0.48 (95% CI: 0.24, 0.97), Advanced WHO clinical staging OR: 2.45 (95% CI: 1.20, 5.01) and a higher level of education; secondary/tertiary OR: 0.16 (95% CI: 0.07, 0.38); 0.11 (95% CI: 0.04, 0.35).

Conclusion

The prevalence of HAND in this study population was found to be high (81.1%). Older age and advanced WHO clinical staging were associated with an increased risk of hand while higher level of education and male gender were protective.

Frequency and Predictors of HIV-Related Cognitive Impairment in East Africa: The Africa Cohort Study (AFRICOS)

BACKGROUND

Medication adherence is a critical issue in achieving viral suppression targets, particularly in resource-limited countries. As HIV-related cognitive impairment (CI) impacts adherence, we examined frequency and predictors of CI in the African Cohort Study.

SETTING

Cross-sectional examination of enrollment data from President's Emergency Plan for AIDS Relief supported clinic sites.

METHODS

In a 30-minute cognitive assessment, CI was defined as -1SD on 2 tests or -2SD on one, as compared with 429 controls. We performed univariable and multivariable logistic and linear models examining clinical and demographic factors associated with CI and global neuropsychological performance (NP-6).

RESULTS

Two thousand four hundred seventy-two HIV+ participants from Kenya (n = 1503), Tanzania (n = 469), and Uganda (n = 500). The mean (SD) age was 39.7 (10.7) years, and 1452 (59%) were women. The majority reported completing or partially completing primary school (n = 1584, 64%). Mean (SD) current and nadir CD4 count were 463 (249) and 204 (221) cells/mm, respectively; 1689 (68%) were on combination antiretroviral therapy. Nine hundred thirty-nine (38%) HIV+ versus 113 (26%) HIV- individuals showed CI: (P < 0.001). We found significant effects of literacy [odds ratio (OR): 0.3; 95% CI: 0.2 to 0.4; P < 0.001] and World Health Organization stage 4 (OR: 1.5; 95% CI: 1.0 to 2.q; P = 0.046) on CI. Tanzanians (OR: 3.2; 95% CI: 2.4 to 4.3; P < 0.001) and Kenyans (OR: 2.0; 95% CI: 1.6 to 2.6; P < 0.001) had higher risk of CI compared with Ugandans. Results were relatively unchanged in predictive models of NP-6, with the only difference being an additional significant effect of current CD4 cell count (coeff: 0.0; 95% CI: 0.0 to 0.0; P = 0.005).

CONCLUSIONS

Literacy, country, World Health Organization stage, and current CD4 cell count were associated with increased risk of cognitive dysfunction. Our findings help optimize care practices in Africa, illustrating the importance of strategies for early and effective viral-immunological control.

Psycho-behavioral factors associated with neurocognitive performance among people living with HIV on antiretroviral therapy in Accra, Ghana

BACKGROUND

It is estimated that almost half of all people living with HIV have some form of neurocognitive impairment, but few studies have looked at the risk of neurocognitive impairment and its associated factors in Ghana, due in part to limited resources for such testing.

OBJECTIVES

To examine neurocognitive performance in a group of Ghanaians living with HIV and possible factors that contribute to their performance.

METHODS

One hundred and four patients were assessed using a selection of brief non-invasive neuropsychological assessments as well as the International HIV Dementia Scale. Psycho-behavioural factors (alcohol use, depression, and medication adherence) as well as demographic characteristics and functional daily activities were assessed to determine their association with neurocognitive performance, using linear regression and receiver operating characteristic analyses.

RESULT

About 48% of the participants met the criteria for risk of neurocognitive impairment. Age, education, and symptoms of depression were found to be significantly associated with the risk of impairment.

CONCLUSION

Some people living with HIV showed risk of neurocognitive impairment, which was significantly associated with education, age and depressive symptoms. It is therefore important to consider routine neurocognitive screening in HIV management to recognize any risks for early interventions.

Mental health research capacity building in sub-Saharan Africa: the African Mental Health Research Initiative

Mental, neurological and substance use (MNS) disorders are a leading, but neglected, cause of morbidity and mortality in sub-Saharan Africa. The treatment gap for MNS is vast with only 10% of people with MNS disorders in low-income countries accessing evidence-based treatments. Reasons for this include low awareness of the burden of MNS disorders and limited evidence to support development, adaptation and implementation of effective and feasible treatments. The overall goal of the African Mental Health Research Initiative (AMARI) is to build an African-led network of MNS researchers in Ethiopia, Malawi, South Africa and Zimbabwe, who are equipped to lead high quality mental health research programs that meet the needs of their countries, and to establish a sustainable career pipeline for these researchers with an emphasis on integrating MNS research into existing programs such as HIV/AIDS. This paper describes the process leading to the development of AMARI's objectives through a theory of change workshop, successes and challenges that have been faced by the consortium in the last 4 years, and the future role that AMARI could play in further building MNS research capacity by brining on board more institutions from low- and middle-income countries with an emphasis on developing an evidence-based training curriculum and a research-driven care service.

Mechanisms and perceived mental health changes after a livelihood intervention for HIV-positive Kenyans: Longitudinal, qualitative findings

While food insecurity and poverty worsen mental health outcomes among people living with HIV/AIDS (PLHIV), few intervention studies have targeted poverty and food insecurity as a way to improve mental health. Among HIV-positive patients, addressing such upstream determinants may prove crucial to ensure better mental health and HIV clinical outcomes. We integrated longitudinal, qualitative research into a randomized trial of a livelihood intervention to understand processes and mechanisms for how the intervention may affect mental health among HIV-infected Kenyan adults. In-depth interviews were conducted with intervention participants (n = 45) and control participants (n = 9) at two time-points (after intervention start and upon intervention end). Interviews (n = 85) were translated, double-coded, and analyzed thematically using an inductive-deductive team approach. Participants reported numerous mental health improvements post-intervention including reduced stress, fewer symptoms of anxiety, improved mood, lower depressive symptoms, fewer repetitive and ruminating thoughts, and more hopefulness for the future. Improvements in mental health appear to occur via several mechanisms including: 1) better food security and income; 2) increased physical activity and ability to create fruitful routines around farm work; and, 3) improved sense of self as an active member of the community. Qualitative, longitudinal interviews may help identify intervention mechanisms for improved mental health, but additional research is required to confirm self-reports of mental health changes. These findings suggest that livelihood interventions may improve mental health in multi-faceted ways, and help PLHIV better integrate with their communities. Trial registered at ClinicalTrials.gov: NCT01548599.

Predictors of Daily Adherence to Naltrexone for Alcohol Use Disorder Treatment During a Mobile Health Intervention

Background

Adherence to medications for treating alcohol use disorder (AUD) is poor. To identify predictors of daily naltrexone adherence over time, a secondary data analysis was conducted of a trial evaluating a mobile health intervention to improve adherence.

Methods

Participants seeking treatment for AUD (n = 58; Mage = 38 years; 71% male) were prescribed naltrexone for 8 weeks. Adherence was tracked using the Medication Event Monitoring System (MEMS). In response to daily text messages, participants reported the previous day's alcohol use, craving, and naltrexone side effects. Using multilevel structural equation modeling (MSEM), we examined baseline dispositional factors and within-person, time-varying factors as predictors of daily adherence.

Results

Naltrexone adherence decreased over time. Adherence was higher on days when individuals completed daily mobile assessments relative to days when they did not (odds ratio [OR] = 2.53, 95% confidence interval [CI] 1.61 to 3.98), irrespective of intervention condition. Days when individuals drank more than their typical amount were related to lower next-day adherence (OR = 0.93, 95% CI 0.88 to 0.99). A similar pattern was supported for craving (OR = 0.88, 95% CI 0.79 to 0.98). Weekend days were associated with lower adherence than weekdays (OR = 0.71, 95% CI 0.58 to 0.86); this effect was partly mediated by heavier daily drinking (indirect effect = -0.02, 95% CI -0.04 to -0.003) and stronger-than-usual craving (indirect effect = -0.01, 95% CI -0.02 to 0.00) on weekend days.

Conclusions

The results further demonstrate the need to improve adherence to AUD pharmacotherapy. The present findings also support developing interventions that target daily-level risk factors for nonadherence. Mobile health interventions may be one means of developing tailored and adaptive adherence interventions.

DSM-5 substance use disorder symptom clusters and HIV antiretroviral therapy (ART) adherence

This study examines self-reported 30-day antiretroviral therapy (ART) adherence among 101 people living with HIV and substance use disorders (SUD) in New York City in terms of Diagnostic and Statistical Manual - 5th Edition (DSM-5) SUD symptom clusters: impaired control, social impairment, risky use and pharmacological criteria. Overall, 60.4% met DSM-5 criteria for stimulant, 55.5% for alcohol, 34.7% for cannabis and 25.7% for opioid SUD. Of the 76 participants with a current ART prescription, 75.3% reported at least 90% 30-day adherence. Participants with vs. without alcohol SUD were significantly less likely to report ART adherence (64.3% vs. 88.2%, p = .017). Endorsement of social impairment significantly differed among adherent vs. non-adherent participants with alcohol SUDs (74.1% vs. 100%, p = .038) and with opioid SUDs (94.1% vs. 50.0%, p = .040). Understanding specific SUD symptom clusters may assist providers and patients in developing strategies to improve ART adherence.