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West NS, Namuganga LP, Isabirye D, Nakubulwa R, Ddaaki W, Nakyanjo N, Nalugoda F, Murray SM, Kennedy CE. 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). RESEARCH SQUARE 2024:rs.3.rs-4697900. [PMID: 39041027 PMCID: PMC11261958 DOI: 10.21203/rs.3.rs-4697900/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/24/2024]
Abstract
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.
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West NS, Nakubulwa R, Murray SM, Ddaaki W, Mayambala D, Nakyanjo N, Nalugoda F, Hutton HE, Surkan PJ, Kennedy CE. Okweraliikirira and Okwenyamira: Idioms of Psychological Distress Among People Living with HIV in Rakai, Uganda. RESEARCH SQUARE 2024:rs.3.rs-4656465. [PMID: 39011105 PMCID: PMC11247927 DOI: 10.21203/rs.3.rs-4656465/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
Introduction Health and illness experiences are positioned within social and cultural contexts. Understanding the mental health and psychological distress of people living with HIV in highly affected communities is critical to addressing their needs and to ensure programming and interventions are targeted and appropriate. Methods Grounded in the ethnomedical theoretical perspective, we conducted qualitative interviews to understand the experience and expression of psychological distress by people living with HIV in Rakai, Uganda. Participants included adults living with HIV (n=20), health workers (counselors, peer health workers, nurses, n=10), and key informants (n=12). Interviews were audio recorded, transcribed/translated, coded, and analyzed using thematic analysis. Results Two idioms of distress, okweraliikirira (worry/apprehension) and okwenyamira (deep/manythoughts/lots of thoughts) were described as impacting people living with HIV. Both idioms were said to be alleviated by social support or counseling, but if left unaddressed could lead to more severe mental health problems and poor ART adherence. Conclusion People living with HIV understand their psychological distress through culturally specific idioms; such distress can have deleterious impacts on well-being. Incorporating idioms of distress into screening and treatment for people living with HIV may improve identification of individuals in need and overall health services to address this need.
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Affiliation(s)
- Nora S West
- Department of Medicine, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine
| | | | - Sarah M Murray
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health
| | | | | | | | | | - Heidi E Hutton
- Johns Hopkins School of Medicine, Division of Psychiatry and Behavioral Sciences
| | - Pamela J Surkan
- Johns Hopkins Bloomberg School of Public Health, Department of International Health
| | - Caitlin E Kennedy
- Johns Hopkins Bloomberg School of Public Health, Department of International Health
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Mthiyane N, Rapulana AM, Harling G, Copas A, Shahmanesh M. Effect of multi-level interventions on mental health outcomes among adolescents in sub-Saharan Africa: a systematic review. BMJ Open 2023; 13:e066586. [PMID: 37788931 PMCID: PMC10551963 DOI: 10.1136/bmjopen-2022-066586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/09/2023] [Indexed: 10/05/2023] Open
Abstract
OBJECTIVE In sub-Saharan Africa (SSA), multiple factors contribute to the considerable burden of mental health disorders among adolescents, highlighting the need for interventions that address underlying risks at multiple levels. We reviewed evidence of the effectiveness of community or family-level interventions, with and without individual level interventions, on mental health disorders among adolescents in SSA. DESIGN Systematic review using the Grades of Recommendation, Assessment, Development and Evaluation approach. DATA SOURCES A systematic search was conducted on Cochrane Library, MEDLINE, EMBASE, PSYCINFO and Web of Science up to 31 March 2021. ELIGIBILITY CRITERIA Studies were eligible for inclusion in the review if they were randomised controlled trials (RCTs) or controlled quasi-experimental studies conducted in sub-Saharan African countries and measured the effect of an intervention on common mental disorders in adolescents aged 10-24 years. DATA EXTRACTION AND SYNTHESIS We included studies that assessed the effect of interventions on depression, anxiety, post-traumatic stress disorder and substance abuse. Substance abuse was only considered if it was measured alongside mental health disorders. The findings were summarised using synthesis without meta-analysis, where studies were grouped according to the type of intervention (multi-level, community-level) and participants. RESULTS Of 1197 studies that were identified, 30 studies (17 RCTs and 3 quasi-experimental studies) were included in the review of which 10 delivered multi-level interventions and 20 delivered community-level interventions. Synthesised findings suggest that multi-level interventions comprise economic empowerment, peer-support, cognitive behavioural therapy were effective in improving mental health among vulnerable adolescents. Majority of studies that delivered interventions to community groups reported significant positive changes in mental health outcomes. CONCLUSIONS The evidence from this review suggests that multi-level interventions can reduce mental health disorders in adolescents. Further research is needed to understand the reliability and sustainability of these promising interventions in different African contexts. PROSPERO REGISTRATION NUMBER CRD42021258826.
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Affiliation(s)
- Nondumiso Mthiyane
- Africa Health Research Institute, Durban, South Africa
- Institute for Global Health, University College London, London, UK
| | - Antony M Rapulana
- Africa Health Research Institute, Durban, South Africa
- School of Laboratory Medicine and Medical Science, University of KwaZulu-Natal, Durban, South Africa
| | - Guy Harling
- Africa Health Research Institute, Durban, South Africa
- Institute for Global Health, University College London, London, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology & Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Andrew Copas
- Institute for Global Health, University College London, London, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, South Africa
- Institute for Global Health, University College London, London, UK
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Rutakumwa R, Tusiime C, Mpango RS, Kyohangirwe L, Kaleebu P, Patel V, Kinyanda E. A Qualitative Exploration of Causes of Depression among Persons Living with HIV Receiving Antiretroviral Therapy in Uganda: Implications for Policy. PSYCHIATRY JOURNAL 2023; 2023:1986908. [PMID: 36704236 PMCID: PMC9873437 DOI: 10.1155/2023/1986908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/12/2022] [Accepted: 12/22/2022] [Indexed: 01/19/2023]
Abstract
Introduction Depression is the fourth leading cause of the global disease burden and worsens the outcome of comorbidities including HIV/AIDS. Depression is particularly problematic among persons living with HIV in sub-Saharan Africa where scarcity of cost-effective interventions is compounded by inadequate understanding of the disease. We examine risk factors for depression among persons living with HIV undergoing antiretroviral treatment in Uganda and discuss policy implications. Methods A qualitative study using a narrative approach was conducted, the formative phase of a large study to develop a model for integrating depression management into routine HIV care in Uganda. Participants were purposively sampled at four public health facilities in Mpigi District. In-depth interviews were conducted with four clinicians, three supervisors, and 11 persons living with HIV and suffering from depression, as were three focus group discussions with lay health workers. Exit interviews were conducted with 17 persons living with HIV who completed/interrupted depression treatment but had not been interviewed. Only data collected from persons living with HIV and lay health workers were analysed for the purpose of this paper. A narrative thematic approach was used in data analysis. Findings. There were several pathways through which lack of family social support reportedly led to depression: worries about disclosure in discordant relationships, false perceptions of social support, stigmatisation and discrimination, and domestic violence. Economic/poverty and other causes were identified, but their role was less significant or moderated by family social support. Conclusion Family social support plays a dominant role-both directly and indirectly-in influencing depression risk. We propose the mainstreaming of formal psychosocial support and a shift from individual to family-focused counselling that targets both persons living with HIV and their family.
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Affiliation(s)
- Rwamahe Rutakumwa
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 50-59 Nakiwogo Road, P.O. Box 49 Entebbe, Uganda
| | - Christine Tusiime
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 50-59 Nakiwogo Road, P.O. Box 49 Entebbe, Uganda
- Butabika National Referral Mental Hospital, Old Port Bell Road, P.O. Box 7017 Kampala, Uganda
| | - Richard Stephen Mpango
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 50-59 Nakiwogo Road, P.O. Box 49 Entebbe, Uganda
| | - Leticia Kyohangirwe
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 50-59 Nakiwogo Road, P.O. Box 49 Entebbe, Uganda
| | - Pontiano Kaleebu
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 50-59 Nakiwogo Road, P.O. Box 49 Entebbe, Uganda
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA
| | - Eugene Kinyanda
- Medical Research Council/Uganda Virus Research Institute & London School of Hygiene and Tropical Medicine Uganda Research Unit, Plot 50-59 Nakiwogo Road, P.O. Box 49 Entebbe, Uganda
- Department of Psychiatry, Makerere University, P.O. Box 7072 Kampala, Uganda
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Miller AP, Espinosa da Silva C, Ziegel L, Mugamba S, Kyasanku E, Malyabe RB, Wagman JA, Mia Ekström A, Nalugoda F, Kigozi G, Nakigozi G, Kagaayi J, Watya S, Kigozi G. Construct validity and internal consistency of the Patient Health Questionnaire-9 (PHQ-9) depression screening measure translated into two Ugandan languages. PSYCHIATRY RESEARCH COMMUNICATIONS 2021; 1:100002. [PMID: 35187539 PMCID: PMC8855962 DOI: 10.1016/j.psycom.2021.100002] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
BACKGROUND In Uganda, depression is a major public health issue because of its direct disease burden and as a risk factor and co-morbidity for other pervasive health issues. Psychometric assessment of translated depression measures is critical to public health planning to ensure proper screening, surveillance, and treatment of depression and related outcomes. We examined aspects of the validity and reliability of the Patient Health Questionnaire-9 (PHQ-9) translated into Luganda and Runyoro in a large population-based cohort of Ugandan adolescents and adults. METHODS Data from the ongoing open cohort AMBSO Population Health Surveillance study were analyzed from the Wakiso and Hoima districts in Uganda. Descriptive statistics were calculated for the overall sample and stratified by translated language. Construct validity was assessed for each translated scale using confirmatory factor analysis for ordinal data. The internal consistency of each translated scale was assessed using Cronbach's alpha, McDonald's omega total and omega hierarchical. RESULTS Compared to the Runyoro-speaking subsample from Hoima (n=2297), participants in the Luganda-speaking subsample from Wakiso (n=672) were older (27 vs 21 years, p < 0.01) and a greater proportion were female (62% vs. 55%, p < 0.01). The Luganda-translated PHQ-9 had a sample mean of 3.46 (SD=3.26), supported a single-factor structure (RMSEA=0.05, CFI=0.96, TLI=0.94), and demonstrated satisfactory internal consistency (Cronbach's alpha=0.73, McDonald's omega total=0.76, McDonald's omega hierarchical=0.53). The Runyoro-translated PHQ-9 had a comparable sample mean of 3.58 (SD=3.00), also supported a one-factor structure (RMSEA=0.08, CFI=0.92, TLI=0.90), and demonstrated satisfactory internal consistency (Cronbach's alpha=0.72, McDonald's omega total=0.76, McDonald's omega hierarchical=0.57). CONCLUSIONS Our preliminary findings indicate that the Luganda and Runyoro translations of the PHQ-9 had satisfactory construct validity and internal consistency in our sample of Ugandan adolescents and adults. Future studies should expand on this promising work by assessing additional psychometric characteristics of these translated measures in other communities in Uganda.
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Affiliation(s)
- Amanda P. Miller
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
- Corresponding author: Amanda P Miler
| | - Cristina Espinosa da Silva
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, La Jolla, CA, USA
- San Diego State University, Department of Epidemiology and Biostatistics, School of Public Health, San Diego State University, San Diego, CA, USA
| | - Leo Ziegel
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Stephen Mugamba
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
- Makerere University Walter Reed Project (MUWRP), Kampala, Uganda
| | - Emma Kyasanku
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
| | - Robert B. Malyabe
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
| | - Jennifer A. Wagman
- Department of Community Health Sciences, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, USA
| | - Anna Mia Ekström
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Fred Nalugoda
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
| | - Grace Kigozi
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
| | - Gertrude Nakigozi
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
| | - Josehp Kagaayi
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
| | - Stephen Watya
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
| | - Godfrey Kigozi
- Africa Medical and Behavioral Sciences Organization (AMBSO), Uro Care Limited, Wakiso District, Uganda
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Internalized stigma, depressive symptoms, and the modifying role of antiretroviral therapy: A cohort study in rural Uganda. SSM - MENTAL HEALTH 2021; 1. [PMID: 35252904 PMCID: PMC8896824 DOI: 10.1016/j.ssmmh.2021.100034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Depression affects over 40% of people with HIV (PHIV) in low- and middle-income countries, and over half of PHIV report HIV-related internalized stigma. However, few longitudinal studies of PHIV have examined the relationship between HIV-related stigma and depression. Data were analyzed from the 2007–15 Uganda AIDS Rural Treatment Outcomes (UARTO) Study, a cohort of 454 antiretroviral therapy (ART)-naïve PHIV (68% women) starting ART. Our primary outcome was depression symptom severity over the first two years of ART, measured using a locally adapted version of the Hopkins Symptom Checklist; our primary exposure was the 6-item Internalized AIDS-Related Stigma Scale. Both scores were measured at enrollment and at quarterly follow-up visits. We fit linear generalized estimating equations (GEE) regression models to estimate the association between stigma and depression symptom severity, adjusting for potential confounders. We included a stigma×time product term to assess the modifying effect of ART on the association between internalized stigma and depression symptom severity. UARTO participants had a median age of 32 years and median enrollment CD4 count of 217 cells/mm3. Both depression symptom severity and internalized stigma declined on ART, particularly during the first treatment year. In multivariable regression models, depression symptom severity was positively associated with internalized stigma (b=0.03; 95% confidence interval [CI], 0.02 to 0.04) and negatively associated with ART duration >6 months (b =− 0.16; 95% CI,− 0.19 to −0.13). The estimated product term coefficient was negative and statistically significant (P = 0.004), suggesting that the association between internalized stigma and depression symptom severity weakened over time on ART. Thus, in this large cohort of PHIV initiating ART in rural Uganda, depression symptom severity was associated with internalized stigma but the association declined with time on ART. These findings underscore the potential value of ART as a stigma reduction intervention for PHIV, particularly during early treatment.
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Using Theory of Change to inform the design of the HIV+D intervention for integrating the management of depression in routine HIV care in Uganda. PLoS One 2021; 16:e0259425. [PMID: 34847165 PMCID: PMC8631669 DOI: 10.1371/journal.pone.0259425] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 10/19/2021] [Indexed: 11/19/2022] Open
Abstract
There is growing recognition of the burden of depression in people living with HIV/AIDS (PLWHA), associated with negative behavioural and clinical outcomes. Unfortunately, most HIV care providers in sub-Saharan Africa do not routinely provide mental health services to address this problem. This article describes the process of developing a model for integrating the management of depression in HIV care in Uganda. Theory of Change (ToC) methodology was used to guide the process of developing the model. Three successive ToC workshops were held with a multi-disciplinary group of 38 stakeholders within Wakiso district, in the Central region of Uganda. The first 2 workshops were for generating practical ideas for a feasible and acceptable model of integrating the management of depression in HIV care at all levels of care within the district healthcare system; while the third and final workshop was for consensus building. Following meaningful brainstorming and discussions, the stakeholders suggested improved mental wellbeing among PLWHA as the ultimate outcome of the program. This would be preceded by short-term and intermediate outcomes including reduced morbidity among persons with HIV attributable to depression, allocation of more resources towards management of depression, increased help-seeking among depressed PLWHA and more health workers detecting and managing depression. These would be achieved following several interventions undertaken at all levels of care. The participants further identified some indicators of successful implementation such as emphasis of depression management in the district healthcare plans, increased demand for anti-depressants etc; as well as various assumptions underlying the intervention. All these were graphically aligned in a causal pathway, leading to a ToC map, contextualizing and summarizing the intervention model. The ToC was a valuable methodology that brought together stakeholders to identify key strategies for development of a comprehensible contextualized intervention model for managing depression within HIV care in Uganda; allowing greater stakeholder engagement and buy-in.
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Bassett IV, Xu A, Giddy J, Bogart LM, Boulle A, Millham L, Losina E, Parker RA. Changing contextual factors from baseline to 9-months post-HIV diagnosis predict 5-year mortality in Durban, South Africa. AIDS Care 2021; 33:1543-1550. [PMID: 33138630 PMCID: PMC8088454 DOI: 10.1080/09540121.2020.1837338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
Changes in an individual's contextual factors following HIV diagnosis may influence long-term outcomes. We evaluated how changes to contextual factors between HIV diagnosis and 9-month follow-up predict 5-year mortality among HIV-infected individuals in Durban, South Africa enrolled in the Sizanani Trial (NCT01188941). We used random survival forests to identify 9-month variables and changes from baseline predictive of time to mortality. We incorporated these into a Cox proportional hazards model including age, sex, and starting ART by 9 months a priori, 9-month social support and competing needs, and changes in mental health between baseline and 9 months. Among 1,154 participants with South African ID numbers, 900 (78%) had baseline and 9-month data available of whom 109 (12%) died after 9-month follow-up. Those who reported less social support at 9 months had a 16% higher risk of mortality. Participants who went without basic needs or healthcare at 9 months had a 2.6 times higher hazard of death compared to participants who did not. Low social support and competing needs at 9-month follow-up substantially increase long-term mortality risk. Reassessing contextual factors during follow-up and targeting interventions to increase social support and affordability of care may reduce long-term mortality for HIV-infected individuals in South Africa.
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Affiliation(s)
- Ingrid V. Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Andrew Boulle
- Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Department of Health, Provincial Government of the Western Cape
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town
| | - Lucia Millham
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert A. Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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Effect of suicidality on clinical and behavioural outcomes in HIV positive adults in Uganda. PLoS One 2021; 16:e0254830. [PMID: 34415901 PMCID: PMC8378732 DOI: 10.1371/journal.pone.0254830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 07/05/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction Suicidality is a risk of a person committing suicide often characterized by suicidal ideation, intent or attempts. Despite the high burden of suicidality among individuals living with HIV and HAIDS, there is paucity of data on the impact of suicidality on clinical (such as CD4 counts and HIV disease progression) and behavioural outcomes (such as adherence to HIV Medications). Cross-sectional investigations of these associations are often complicated by bidirectional causal relationships and hence the need for longitudinal study designs. We conducted a cohort study to determine the impact of suicidality on clinical and behavioural outcomes among adults living with HIV/AIDS in Uganda. Materials and methods We conducted the study among 1099 ART naïve adults living with HIV/AIDS in Uganda. Data were collected at three time points: baseline, 6 and 12 months. Multiple regression and discrete time survival models were used to determine the relationship between suicidality and indices of HIV outcomes. Results Majority of the participants were female and the participant mean age was 35 years. Most of them (73%) had primary or no formal education. The proportion of participants with suicidality decreased from 2.9% at baseline to roughly 1% both at month 6 and month 12. Of the investigated clinical and behavioural outcomes, baseline suicidality only had a negative impact on missing a dose of ART where the odds of missing a dose of ART were 8.25 (95% CI 2.45–27.71, p>0.01) times higher for participants with suicidality compared to those without suicidality. The following outcomes were not significantly impacted by baseline suicidality: HIV clinical stage, CD4 count and risky sexual behaviour. Conclusions The fact that baseline suicidality significantly negatively impacted ART adherence calls for the incorporation of psychosocial interventions to target indices of psychological distress such as suicidality to improve HIV related outcomes.
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Rutakumwa R, Ssebunnya J, Mugisha J, Mpango RS, Tusiime C, Kyohangirwe L, Taasi G, Sentongo H, Kaleebu P, Patel V, Kinyanda E. Stakeholders' perspectives on integrating the management of depression into routine HIV care in Uganda: qualitative findings from a feasibility study. Int J Ment Health Syst 2021; 15:63. [PMID: 34210344 PMCID: PMC8247159 DOI: 10.1186/s13033-021-00486-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 06/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND HIV/AIDS continues to be a major global public health problem with Eastern and Southern Africa being the regions most affected. With increased access to effective antiretroviral therapy, HIV has become a chronic and manageable disease, bringing to the fore issues of quality of life including mental wellbeing. Despite this, the majority of HIV care providers in sub-Saharan Africa, including Uganda's Ministry of Health, do not routinely provide mental health care including depression management. The purpose of this paper is to explore stakeholders' perspectives on the feasibility and acceptability of integrating depression management into routine adult HIV care. The paper addresses a specific objective of the formative phase of the HIV + D study aimed at developing and evaluating a model for integrating depression management into routine HIV care in Uganda. METHODS This was a qualitative study. Data were collected through in-depth interviews with 11 patients at enrollment and follow-up in the pilot phase, and exit interviews with 11 adherent patients (those who completed their psychotherapy sessions) and six non-adherent patients (those missing at least two sessions) at the end of the pilot phase. Key informant interviews were held with four clinicians, five supervisors and one mental health specialist, as were three focus group discussions with lay health workers. These were purposively sampled at four public health facilities in Mpigi District. Data were analysed thematically. RESULTS Patients highlighted the benefits of treating depression in the context of HIV care, including improved adherence to antiretroviral therapy, overcoming sleeplessness and suicidal ideation, and regaining a sense of self-efficacy. Although clinicians and other stakeholders reported benefits of treating depression, they cited challenges in managing depression with HIV care, which were organisational (increased workload) and patient related (extended waiting time and perceptions of preferential treatment). Stakeholders generally shared perspectives on how best to integrate, including recommendations for organisational level interventions-training, harmonisation in scheduling appointments and structural changes-and patient level interventions to enhance knowledge about depression. CONCLUSIONS Integrating depression management into routine HIV care in Uganda is acceptable among key stakeholders, but the technical and operational feasibility of integration would require changes both at the organisational and patient levels.
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Affiliation(s)
- Rwamahe Rutakumwa
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship, Mental Health Section, 50-59 Nakiwogo Street, Entebbe, Uganda.
| | - Joshua Ssebunnya
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship, Mental Health Section, 50-59 Nakiwogo Street, Entebbe, Uganda.,Butabika National Referral Mental Hospital, Old Port Bell Road, Kampala, Uganda
| | | | - Richard Steven Mpango
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship, Mental Health Section, 50-59 Nakiwogo Street, Entebbe, Uganda
| | - Christine Tusiime
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship, Mental Health Section, 50-59 Nakiwogo Street, Entebbe, Uganda.,Butabika National Referral Mental Hospital, Old Port Bell Road, Kampala, Uganda
| | - Leticia Kyohangirwe
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship, Mental Health Section, 50-59 Nakiwogo Street, Entebbe, Uganda
| | - Geoffrey Taasi
- STD/AIDS Control Program, Ministry of Health, Ministry of Health, Kampala, Uganda
| | - Hafsa Sentongo
- Mental Health Division, Ministry of Health, Kampala, Uganda
| | - Pontiano Kaleebu
- Director of the MRC/UVRI & LSHTM Uganda Research Unit, Kampala, Uganda
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Eugene Kinyanda
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship, Mental Health Section, 50-59 Nakiwogo Street, Entebbe, Uganda.,Department of Psychiatry, Makerere University, Kampala, Uganda
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Kinyanda E, Kyohangirwe L, Mpango RS, Tusiime C, Ssebunnya J, Katumba K, Tenywa P, Mugisha J, Taasi G, Sentongo H, Akena D, Laurence Y, Muhwezi W, Weiss HA, Neuman M, Greco G, Knizek B, Levin J, Kaleebu P, Araya R, Ssembajjwe W, Patel V. Effectiveness and cost-effectiveness of integrating the management of depression into routine HIV Care in Uganda (the HIV + D trial): A protocol for a cluster-randomised trial. Int J Ment Health Syst 2021; 15:45. [PMID: 33980299 PMCID: PMC8114695 DOI: 10.1186/s13033-021-00469-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 05/02/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An estimated 8-30 % of people living with HIV (PLWH) have depressive disorders (DD) in sub-Saharan Africa. Of these, the majority are untreated in most of HIV care services. There is evidence from low- and middle- income countries of the effectiveness of both psychological treatments and antidepressant medication for the treatment of DD among PLWH, but no evidence on how these can be integrated into routine HIV care. This protocol describes a cluster-randomised trial to evaluate the effectiveness and cost-effectiveness of the HIV + D model for the integration of a collaborative stepped care intervention for DD into routine HIV care, which we have developed and piloted in Uganda. METHODS Forty public health care facilities that provide HIV care in Kalungu, Masaka and Wakiso Districts will be randomly selected to participate in the trial. Each facility will recruit 10-30 eligible PLWH with DD and the total sample size will be 1200. The clusters will be randomised 1:1 to receive Enhanced Usual Care alone (EUC, i.e. HIV clinicians trained in Mental Health Gap Action Programme including guidelines on when and where to refer patients for psychiatric care) or EUC plus HIV + D (psychoeducation, Behavioural Activation, antidepressant medication and referral to a supervising mental health worker, delivered in a collaborative care stepwise approach). Eligibility criteria are PLWH attending the clinic, aged ≥ 18 years who screen positive on a depression screening questionnaire (Patient Health Questionnaire, PHQ-9 ≥ 10). The primary outcome is the mean depressive disorder symptom severity scores (assessed using the PHQ-9) at 3 months' post-randomisation, with secondary mental health, disability, HIV and economic outcomes measured at 3 and 12 months. The cost-effectiveness of EUC with HIV + D will be assessed from both the health system and the societal perspectives by collecting health system, patient and productivity costs and mean DD severity scores at 3 months, additional to health and non-health related quality of life measures (EQ-5D-5 L and OxCAP-MH). DISCUSSION The study findings will inform policy makers and practitioners on the cost-effectiveness of a stepped care approach to integrate depression management in routine care for PLWH in low-resource settings. TRIAL REGISTRATION ISRCTN, ISRCTN86760765. Registered 07 September 2017, https://doi.org/10.1186/ISRCTN86760765 .
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Affiliation(s)
- Eugene Kinyanda
- MRC/UVRI & LSHTM Uganda Research Unit, Mental Health Section, Entebbe, Uganda
| | - Leticia Kyohangirwe
- MRC/UVRI & LSHTM Uganda Research Unit, Mental Health Section, Entebbe, Uganda.
| | - Richard S Mpango
- MRC/UVRI & LSHTM Uganda Research Unit, Mental Health Section, Entebbe, Uganda
| | - Christine Tusiime
- MRC/UVRI & LSHTM Uganda Research Unit, Mental Health Section, Entebbe, Uganda
| | | | - Kenneth Katumba
- MRC/UVRI & LSHTM Uganda Research Unit, Mental Health Section, Entebbe, Uganda
| | - Patrick Tenywa
- MRC/UVRI & LSHTM Uganda Research Unit, Mental Health Section, Entebbe, Uganda
| | | | | | | | - Dickens Akena
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Yoko Laurence
- Department for Global Health and Development, Public Health and Policy, London School of Hygiene & Tropical Medicine, Centre for Health Economics in London, London, England
| | - Wilson Muhwezi
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Helen A Weiss
- MRC International Statistics and Epidemiology Group LSHTM, London, England
| | - Melissa Neuman
- MRC International Statistics and Epidemiology Group LSHTM, London, England
| | - Giulia Greco
- Department for Global Health and Development, Public Health and Policy, London School of Hygiene & Tropical Medicine, Centre for Health Economics in London, London, England
| | - Birthe Knizek
- Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway
| | - Jonathan Levin
- Department Statistics, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Ricardo Araya
- Centre for Global Mental Health, Kings College London, London, England
| | - Wilber Ssembajjwe
- MRC/UVRI & LSHTM Uganda Research Unit, Mental Health Section, Entebbe, Uganda
| | - Vikram Patel
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
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12
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Kalungi A, Womersley JS, Kinyanda E, Joloba ML, Ssembajjwe W, Nsubuga RN, Seedat S, Hemmings SMJ. The 5-HTTLPR-rs25531 S-A-S-A Haplotype and Chronic Stress Moderate the Association Between Acute Stress and Internalizing Mental Disorders Among HIV+ Children and Adolescents in Uganda. Front Genet 2021; 12:649055. [PMID: 33968131 PMCID: PMC8104030 DOI: 10.3389/fgene.2021.649055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 03/26/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Internalizing mental disorders (IMDs) among HIV-positive (HIV+) children and adolescents are associated with poor disease outcomes, such as faster HIV disease progression. Although it has been suggested that the development of IMDs is moderated by interaction of stressful life events and vulnerability factors, the underlying etiology is largely unknown. Serotonin transporter gene [solute carrier family 6 member A4 (SLC6A4)] and human tryptophan hydroxylase 2 gene (TPH2) polymorphisms have been implicated in the development of IMDs. This study investigated the association between acute stress and IMDs, and moderation by chronic stress and genetic variants in SLC6A4 and TPH2. Hypothesis: Acute stress acts through genetic and environmental vulnerability factors to increase the risk of developing IMDs. Methods: Polymorphisms in SLC6A4 (5-HTTLPR, rs25531, 5-HTTLPR-rs25531, and STin2 VNTR) and TPH2 (rs1843809, rs1386494, rs4570625, and rs34517220) were genotyped in 368 HIV+ children and adolescents (aged 5-17 years) with any internalizing mental disorder (depression, anxiety disorders, or posttraumatic stress disorder), and 368 age- and sex-matched controls, who were also HIV+. Chronic and acute stress categories were derived by hierarchical cluster analysis. Logistic regression analysis was used to assess the independent moderating effect of chronic stress and each selected polymorphism on the association between acute stress and IMDs. Results: We observed a statistically significant association between severe acute stress and IMDs (p = 0.001). Children and adolescents who experienced severe acute stress were twice as likely to develop IMDs, compared to children and adolescents who experienced mild acute stress (p = 0.001). Chronic stress interacted with severe acute stress to increase the risk of IMDs (p = 0.033). Acute stress was found to interact with 5-HTTLPR-rs25531 S-A-S-A haplotype to increase the risk for IMDs among Ugandan HIV+ children and adolescents (p = 0.049). We found no evidence for a combined interaction of acute stress, chronic stress, and 5-HTTLPR-rs25531 on IMDs. Conclusion: The odds of having an internalizing mental disorder (IMD) were higher among HIV+ children and adolescents who experienced severe acute stress compared to HIV+ children and adolescents who experienced mild acute stress. Chronic stress and 5-HTTLPR-rs25531 independently moderated the association between acute stress and IMDs.
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Affiliation(s)
- Allan Kalungi
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- Mental Health Project, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Psychiatry, Makerere University, Kampala, Uganda
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
| | - Jacqueline S. Womersley
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- South African Medical Research Council/Stellenbosch University Genomics of Brain Disorders Research Unit, Cape Town, South Africa
| | - Eugene Kinyanda
- Mental Health Project, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Psychiatry, Makerere University, Kampala, Uganda
| | - Moses L. Joloba
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Wilber Ssembajjwe
- Mental Health Project, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- MRC/UVRI and LSHTM Uganda Research Unit, Statistics and Data Science Section, Entebbe, Uganda
| | - Rebecca N. Nsubuga
- MRC/UVRI and LSHTM Uganda Research Unit, Statistics and Data Science Section, Entebbe, Uganda
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- South African Medical Research Council/Stellenbosch University Genomics of Brain Disorders Research Unit, Cape Town, South Africa
| | - Sian M. J. Hemmings
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- South African Medical Research Council/Stellenbosch University Genomics of Brain Disorders Research Unit, Cape Town, South Africa
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13
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Katumba KR, Laurence YV, Tenywa P, Ssebunnya J, Laszewska A, Simon J, Vassall A, Kinyanda E, Greco G. Cultural and linguistic adaptation of the multi-dimensional OXCAP-MH for outcome measurement of mental health among people living with HIV/AIDS in Uganda: the Luganda version. J Patient Rep Outcomes 2021; 5:32. [PMID: 33826007 PMCID: PMC8026780 DOI: 10.1186/s41687-021-00306-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/24/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND It is rare to find HIV/AIDS care providers in sub-Saharan Africa routinely providing mental health services, yet 8-30% of the people living with HIV have depression. In an ongoing trial to assess integration of collaborative care of depression into routine HIV services in Uganda, we will assess quality of life using the standard EQ-5D-5L, and the capability-based OxCAP-MH which has never been adapted nor used in a low-income setting. We present the results of the translation and validation process for cultural and linguistic appropriateness of the OxCAP-MH tool for people living with HIV/AIDS and depression in Uganda. METHODS The translation process used the Concept Elaboration document, the source English version of OxCAP-MH, and the Back-Translation Review template as provided during the user registration process of the OxCAP-MH, and adhered to the Translation and Linguistic Validation process of the OxCAP-MH, which was developed following the international principles of good practice for translation as per the International Society for Pharmacoeconomics and Outcomes Research's standards. RESULTS The final official Luganda version of the OxCAP-MH was obtained following a systematic iterative process, and is equivalent to the English version in content, but key concepts were translated to ensure cultural acceptability, feasibility and comprehension by Luganda-speaking people. CONCLUSION The newly developed Luganda version of the OxCAP-MH can be used both as an alternative or as an addition to health-related quality of life patient-reported outcome measures in research about people living with HIV with comorbid depression, as well as more broadly for mental health research.
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Affiliation(s)
- Kenneth R. Katumba
- MRC/UVRI & LSHTM Uganda Research Unit (Social Aspects of Health), Plot 51-59 Nakiwogo Road, Entebbe, +256 Uganda
| | - Yoko V. Laurence
- Centre for Health Economics in London, (Department of Global Health and Development), London School of Hygiene & Tropical Medicine, London, UK
| | - Patrick Tenywa
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship (Mental Health Section), Entebbe, Uganda
| | - Joshua Ssebunnya
- Butabika National Referral and Teaching Mental Hospital, Kampala, Uganda
| | - Agata Laszewska
- Center for Public Health, (Department of Health Economics), Medical University of Vienna, Vienna, Austria
| | - Judit Simon
- Center for Public Health, (Department of Health Economics), Medical University of Vienna, Vienna, Austria
- University of Oxford, (Department of Psychiatry and HERC), Oxford, UK
| | - Anna Vassall
- Centre for Health Economics in London, (Department of Global Health and Development), London School of Hygiene & Tropical Medicine, London, UK
| | - Eugene Kinyanda
- MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship (Mental Health Section), Entebbe, Uganda
| | - Giulia Greco
- Centre for Health Economics in London, (Department of Global Health and Development), London School of Hygiene & Tropical Medicine, London, UK
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14
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Mthiyane N, Harling G, Chimbindi N, Baisley K, Seeley J, Dreyer J, Zuma T, Birdthistle I, Floyd S, McGrath N, Tanser F, Shahmanesh M, Sherr L. Common mental disorders and HIV status in the context of DREAMS among adolescent girls and young women in rural KwaZulu-Natal, South Africa. BMC Public Health 2021; 21:478. [PMID: 33691665 PMCID: PMC7945212 DOI: 10.1186/s12889-021-10527-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 02/28/2021] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND HIV affects many adolescent girls and young women (AGYW) in South Africa. Given the bi-directional HIV and mental health relationship, mental health services may help prevent and treat HIV in this population. We therefore examined the association between common mental disorders (CMD) and HIV-related behaviours and service utilisation, in the context of implementation of the combination DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) HIV prevention programme in rural uMkhanyakude district, KwaZulu-Natal. DREAMS involved delivering a package of multiple interventions in a single area to address multiple sources of HIV risk for AGYW. METHODS We analysed baseline data from an age-stratified, representative cohort of 13-22 year-old AGYW. We measured DREAMS uptake as a count of the number of individual-level or community-based interventions each participant received in the last 12 months. CMD was measured using the validated Shona Symptom Questionnaire, with a cut off score ≥ 9 indicating probable CMD. HIV status was ascertained through home-based serotesting. We used logistic regression to estimate the association between CMD and HIV status adjusting for socio-demographics and behaviours. RESULTS Probable CMD prevalence among the 2184 respondents was 22.2%, increasing steadily from 10.1% among 13 year-old girls to 33.1% among 22 year-old women. AGYW were more likely to report probable CMD if they tested positive for HIV (odds ratio vs. test negative: 1.88, 95% confidence interval: 1.40-2.53). After adjusting for socio-demographics and behaviours, there was evidence that probable CMD was more prevalent among respondents who reported using multiple healthcare-related DREAMS interventions. CONCLUSION We found high prevalence of probable CMD among AGYW in rural South Africa, but it was only associated with HIV serostatus when not controlling for HIV acquisition risk factors. Our findings highlight that improving mental health service access for AGYW at high risk for HIV acquisition might protect them. Interventions already reaching AGYW with CMD, such as DREAMS, can be used to deliver mental health services to reduce both CMD and HIV risks. There is a need to integrate mental health education into existing HIV prevention programmes in school and communities.
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Affiliation(s)
| | - Guy Harling
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
- MRC/Wits Rural Public Health & Health Transitions Research Unit (Agincourt), University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology & Harvard Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- University of KwaZulu-Natal, Durban, South Africa
| | - Natsayi Chimbindi
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Kathy Baisley
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Janet Seeley
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Jaco Dreyer
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | - Thembelihle Zuma
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
| | | | - Sian Floyd
- London School of Hygiene and Tropical Medicine, London, UK
| | - Nuala McGrath
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- London School of Hygiene and Tropical Medicine, London, UK
| | - Frank Tanser
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
- University of Southampton, Southampton, UK
- University of Lincoln, Lincoln, UK
| | - Maryam Shahmanesh
- Africa Health Research Institute, Durban, KwaZulu-Natal, South Africa
- Institute for Global Health, University College London, London, UK
- University of KwaZulu-Natal, Durban, South Africa
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
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15
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Kalungi A, Kinyanda E, Womersley JS, Joloba ML, Ssembajjwe W, Nsubuga RN, Kaleebu P, Levin J, Kidd M, Seedat S, Hemmings SMJ. TERT rs2736100 and TERC rs16847897 genotypes moderate the association between internalizing mental disorders and accelerated telomere length attrition among HIV+ children and adolescents in Uganda. BMC Med Genomics 2021; 14:15. [PMID: 33407441 PMCID: PMC7789327 DOI: 10.1186/s12920-020-00857-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 12/14/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Internalizing mental disorders (IMDs) (depression, anxiety and post-traumatic stress disorder) have been associated with accelerated telomere length (TL) attrition; however, this association has not been investigated in the context of genetic variation that has been found to influence TL. We have previously reported an association between IMDs and accelerated TL attrition among Ugandan HIV+ children and adolescents. This study investigated the moderating effects of selected single nucleotide polymorphisms in the telomerase reverse transcriptase gene (TERT) (rs2736100, rs7726159, rs10069690 and rs2853669) and the telomerase RNA component gene (TERC) (rs12696304, rs16847897 and rs10936599) on the association between IMDs and TL, among Ugandan HIV+ children (aged 5-11 years) and adolescents (aged 12-17 years). RESULTS We found no significant interaction between IMDs as a group and any of the selected SNPs on TL at baseline. We observed significant interactions of IMDs with TERT rs2736100 (p = 0.007) and TERC rs16847897 (p = 0.012), respectively, on TL at 12 months. CONCLUSIONS TERT rs2736100 and TERC rs16847897 moderate the association between IMDs and TL among Ugandan HIV+ children and adolescents at 12 months. Understanding the nature of this association may shed light on the pathophysiological mechanisms underlying advanced cellular aging in IMDs.
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Affiliation(s)
- Allan Kalungi
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa.
- Mental Health Section, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda.
- Department of Medical Microbiology, Makerere University, Kampala, Uganda.
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda.
| | - Eugene Kinyanda
- Mental Health Section, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Department of Psychiatry, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jacqueline S Womersley
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- South African Medical Research Council/Stellenbosch University Genomics of Brain Disorders Research Unit, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Moses L Joloba
- Department of Medical Microbiology, Makerere University, Kampala, Uganda
- School of Biomedical Sciences, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Wilber Ssembajjwe
- Mental Health Section, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Statistics and Data Science Section, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Rebecca N Nsubuga
- Statistics and Data Science Section, MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | - Jonathan Levin
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
| | - Martin Kidd
- Centre for Statistical Consultation, Department of Statistics and Actuarial Sciences, University of Stellenbosch, Cape Town, South Africa
| | - Soraya Seedat
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- South African Medical Research Council/Stellenbosch University Genomics of Brain Disorders Research Unit, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sian M J Hemmings
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
- South African Medical Research Council/Stellenbosch University Genomics of Brain Disorders Research Unit, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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16
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Mills JC, Pence BW, Edmonds A, Adedimeji A, Schwartz RM, Kassaye S, Cocohoba J, Cohen MH, Neigh G, Fischl MA, Kempf MC, Adimora AA. The Impact of Cumulative Depression Along the HIV Care Continuum in Women Living With HIV During the Era of Universal Antiretroviral Treatment. J Acquir Immune Defic Syndr 2019; 82:225-233. [PMID: 31335585 PMCID: PMC6791755 DOI: 10.1097/qai.0000000000002140] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Data are limited on cumulative impacts of depression on engagement in care and HIV outcomes in women living with HIV (WLWH) during the era of universal antiretroviral therapy (ART). Understanding the relationship of accumulated depression with HIV disease management may help identify benefits of interventions to reduce severity and duration of depressive episodes. SETTING A cohort of WLWH (N = 1491) from the Women's Interagency HIV Study at 9 sites across the US. METHODS This longitudinal observational cohort study (2013-2017) followed WLWH for a maximum of 9 semiannual visits. Depression was quantified as a time-updated measure of percent of days depressed (PDD) created from repeated assessments using the Center for Epidemiologic Studies Depression scale. Marginal structural Poisson regression models were used to estimate the effects of PDD on the risks of missing an HIV care appointment, <95% ART adherence, and virological failure (≥200 copies/mL). RESULTS The risk of missing an HIV care appointment [risk ratio (RR) = 1.16, 95% confidence interval = 0.93 to 1.45; risk difference (RD) = 0.01, -0.01 to 0.03], being <95% ART adherent (RR = 1.27, 1.06-1.52; RD = 0.04, -0.01 to 0.07), and virological failure (RR = 1.09, 1.01-1.18; RD = 0.01, -0.01 to 0.03) increased monotonically with increasing PDD (comparing those with 25 to those with 0 PDD). The total effect of PDD on virological failure was fully (%100) mediated by being <95% ART adherent. CONCLUSIONS Time spent depressed increases the risk of virological failure through ART adherence, even in the era of universal ART regimes forgiving of imperfect adherence.
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Affiliation(s)
- Jon C Mills
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Andrew Edmonds
- Department of Epidemiology, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, NY
| | - Rebecca M Schwartz
- Department of Occupational Medicine, Epidemiology and Prevention, Zucker School of Medicine at Hofstra/Northwell, Great Neck, NY
| | - Seble Kassaye
- Department of Infectious Diseases, Georgetown University Medical Center, Georgetown University, Washington, DC
| | - Jennifer Cocohoba
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, CA
| | - Mardge H Cohen
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL
| | - Gretchen Neigh
- Department of Anatomy and Neurobiology, School of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Margaret A Fischl
- Department of Medicine/Infectious Diseases, Miami Center for AIDS Research, University of Miami, Miller School of Medicine, Miami, FL
| | - Mirjam-Colette Kempf
- Schools of Nursing, Public Health and Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Adaora A Adimora
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Jiang H, Tan Z, Cheng W, Xu M, Lin P, Huang X, Huang R, Liu J, Yang F, Li Y, Gao Y, Yang Y. Negative life events and major depressive disorder among HIV-positive individuals in Guangdong, China: A cross-sectional study. Medicine (Baltimore) 2019; 98:e17174. [PMID: 31517872 PMCID: PMC6750241 DOI: 10.1097/md.0000000000017174] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
HIV-positive individuals encounter a number of negative life events (NLEs). This cross-sectional study aimed to evaluate the association between NLEs and major depressive disorder (MDD) among HIV-positive individuals in Guangdong, China, about which little is known.HIV-positive individuals were recruited from the Centers for Disease Prevention and Control of Guangzhou, Zhongshan, and Yangjiang from September 2007 to September 2008. Data on NLEs were collected using a questionnaire. The Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition (SCID-I/P) based on the DSM-IV criteria was used to diagnose MDD. Multiple logistic regression analyses were conducted to evaluate the association between NLEs and MDD.Among the 339 participants, 306 (90.27%) reported that one or more NLEs had ever occurred. Participants who reported NLEs that included HIV infection, financial problems, AIDS diagnosis, HIV/AIDS discrimination, conflict with spouse or lover, conflict with other family members, problems in childbearing, and conflict with nonfamily were at a higher risk of MDD. Participants who reported more NLEs in the last year had a higher risk of MDD (OR = 2.86, 95%CI: 1.76-4.65) than individuals who reported fewer NLEs. Individuals with higher chronic stress scores had a higher risk of MDD (OR = 4.36, 95%CI: 2.44-7.78) than individuals with lower chronic stress scores. However, acute stress was not associated with MDD.NLEs were common among HIV-positive individuals. MDD was associated with a greater number of NLEs and the increased chronic stress caused by the NLEs. Interventions should be tailored to those who reported NLEs to help reduce the risk of MDD and increase the quality of life among HIV-positive individuals.
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Affiliation(s)
- Hongbo Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University
| | - Zhimin Tan
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University
| | - Weibin Cheng
- Guangzhou Center for Disease Control and Prevention
| | - Meizhen Xu
- Haizhu District Center for Disease Control and Prevention
| | - Peng Lin
- Guangdong Provincial Center for Disease Control and Prevention
| | | | - Ruoyan Huang
- Guangzhou Psychiatric Hospital, Guangzhou, China
| | - Jun Liu
- Guangdong Provincial Center for Disease Control and Prevention
| | - Fang Yang
- Guangdong Provincial Center for Disease Control and Prevention
| | - Yan Li
- Guangdong Provincial Center for Disease Control and Prevention
| | - Yanhui Gao
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University
| | - Yi Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University
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Bassett IV, Xu A, Giddy J, Bogart LM, Boulle A, Millham L, Losina E, Parker RA. Assessing rates and contextual predictors of 5-year mortality among HIV-infected and HIV-uninfected individuals following HIV testing in Durban, South Africa. BMC Infect Dis 2019; 19:751. [PMID: 31455229 PMCID: PMC6712739 DOI: 10.1186/s12879-019-4373-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 08/12/2019] [Indexed: 01/06/2023] Open
Abstract
Background Little is known about contextual factors that predict long-term mortality following HIV testing in resource-limited settings. We evaluated the impact of contextual factors on 5-year mortality among HIV-infected and HIV-uninfected individuals in Durban, South Africa. Methods We used data from the Sizanani trial (NCT01188941) in which adults (≥18y) were enrolled prior to HIV testing at 4 outpatient sites. We ascertained vital status via the South African National Population Register. We used random survival forests to identify the most influential predictors of time to death and incorporated these into a Cox model that included age, gender, HIV status, CD4 count, healthcare usage, health facility type, mental health, and self-identified barriers to care (i.e., service delivery, financial, logistical, structural and perceived health). Results Among 4816 participants, 39% were HIV-infected. Median age was 31y and 49% were female. 380 of 2508 with survival information (15%) died during median follow-up of 5.8y. For both HIV-infected and HIV-uninfected participants, each additional barrier domain increased the HR of dying by 11% (HR 1.11, 95% CI 1.05–1.18). Every 10-point increase in mental health score decreased the HR by 7% (HR 0.93, 95% CI 0.89–0.97). The hazard ratio (HR) for death of HIV-infected versus HIV-uninfected varied by age: HR of 6.59 (95% CI: 4.79–9.06) at age 20 dropping to a HR of 1.13 (95% CI: 0.86–1.48) at age 60. Conclusions Independent of serostatus, more self-identified barrier domains and poorer mental health increased mortality risk. Additionally, the impact of HIV on mortality was most pronounced in younger persons. These factors may be used to identify high-risk individuals requiring intensive follow up, regardless of serostatus. Trial registration Clinical Trials.gov Identifier NCT01188941. Registered 26 August 2010. Electronic supplementary material The online version of this article (10.1186/s12879-019-4373-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingrid V Bassett
- Division of Infectious Diseases, Massachusetts General Hospital, 100 Cambridge Street, 16th Floor, Boston, MA, 02114, USA. .,Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA. .,Harvard Medical School, Boston, MA, USA. .,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.
| | - Ai Xu
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Andrew Boulle
- Centre for Infectious Diseases, Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa.,Department of Health, Provincial Government of the Western Cape, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Lucia Millham
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA
| | - Elena Losina
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Robert A Parker
- Medical Practice Evaluation Center, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA.,Harvard University Center for AIDS Research, Harvard University, Boston, MA, USA.,Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
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Rates, types and co-occurrence of emotional and behavioural disorders among perinatally HIV-infected youth in Uganda: the CHAKA study. Soc Psychiatry Psychiatr Epidemiol 2019; 54:415-425. [PMID: 30788554 DOI: 10.1007/s00127-019-01675-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 02/12/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To describe the rates, types and comorbidity of emotional and behavioural disorders among perinatally HIV-infected children and adolescents attending care at five HIV youth clinics in Central and Southwestern Uganda. METHODS 1339 CA-HIV attending care at HIV youth clinics in Uganda were interviewed using the DSM-5-based Child and Adolescent Symptom Inventory-5 (CASI-5; caregiver reported) and the Youth Inventory-4R (YI-4R; youth reported). Prevalence, risk factors and comorbidity for psychiatric disorders were estimated using logistic regression models. RESULTS According to caregiver or youth report, the prevalence of 'any DSM-5 psychiatric disorder' was 17.4% (95% CI 15.4-19.5%), while that of 'any behavioural disorder' was 9.6% (95% CI 8.1-11.2%) and that of 'any emotional disorder' was 11.5% (95% CI 9.9-13.3%). The most prevalent behavioural disorder was attention deficit hyperactivity disorder (5.3%), while the most prevalent emotional disorder was separation anxiety disorder (4.6%). The statistically significant risk factors were: for behavioural disorders, sex (more among males than females) and age group (more among adolescents than among children); for emotional disorders, age group (more among adolescents than among children) and the caregiver's highest educational attainment (more among CA-HIV with caregivers with secondary education and higher, than among CA-HIV with caregivers with no formal education or only primary level education). About a quarter (24.5%) of CA-HIV with at least one emotional disorder and about a third (33.5%) of the CA-HIV with at least one behavioural disorder had a comorbid psychiatric disorder. CONCLUSION There was a considerable burden of psychiatric disorders among CA-HIV that spanned a broad spectrum and showed considerable comorbidity.
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Jiang H, Chen S, Huang X, Huang R, Lin P, Cheng W, Xu M, Yang F, Liu J, Li Y, Gao Y, Yang Y. Prevalence of and factors associated with major depressive disorder among HIV-positive individuals in Guangdong, China. J Affect Disord 2019; 246:474-479. [PMID: 30599371 DOI: 10.1016/j.jad.2018.12.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 12/03/2018] [Accepted: 12/25/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND People living with HIV may suffer from mental disorders. We aimed to explore the prevalence of and factors associated with major depressive disorder (MDD) among HIV-positive individuals in Guangdong, China, about which little is known. METHODS A cross-sectional study was conducted to recruit HIV-positive individuals from the Centers for Disease Prevention and Control of Guangzhou, Zhongshan, and Yangjiang from September 2007 to September 2008. Data were collected by questionnaires. MDD was diagnosed and assessed by two psychiatrists using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders-Patient Edition (SCID-I/P) based on the DSM-IV criteria. Multiple logistic regression analyses were conducted to explore the factors associated with MDD. RESULTS The prevalences of lifetime MDD and current MDD among the 339 included participants were 22.71% (95% confidence interval [CI]: 18.25-27.17%) and 12.09% (95%CI: 8.62%-15.57%), respectively. The results of multiple logistic regression showed that patients with AIDS had a higher risk of lifetime MDD (odds ratio [OR] = 2.69, 95%CI: 1.38-5.26) and current MDD (OR = 3.51, 95%CI: 1.59-7.75) than HIV-infected individuals. Participants with more number of negative life events were more likely to have lifetime MDD (OR = 2.33, 95%CI: 1.34-4.06) and current MDD (OR = 3.77, 95%CI: 1.76-8.09) than individuals with fewer negative life events. Individuals with higher score of social support were less likely to have lifetime MDD (OR = 0.45, 95%CI: 0.26-0.80) and current MDD (OR = 0.46, 95%CI: 0.21-0.97) than individuals with less social support. CONCLUSIONS The prevalence of MDD was high among HIV-positive individuals in China. AIDS diagnosis, decreased social support, and an increased number of negative life events were risk factors for MDD.
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Affiliation(s)
- Hongbo Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, No. 283 Jianghai Road, Haizhu District, Guangzhou, China
| | - Shuyi Chen
- The Second People's Hospital of Bao'an District (Group) General Hospital, Shenzhen, China
| | | | - Ruoyan Huang
- Guangzhou Psychiatric Hospital, Guangzhou, China
| | - Peng Lin
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Weibin Cheng
- Guangzhou Center for Disease Control and Prevention, Guangzhou, China
| | - Meizhen Xu
- Haizhu District Center for Disease Control and Prevention, Guangzhou, China
| | - Fang Yang
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Jun Liu
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Yan Li
- Guangdong Provincial Center for Disease Control and Prevention, Guangzhou, China
| | - Yanhui Gao
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, No. 283 Jianghai Road, Haizhu District, Guangzhou, China.
| | - Yi Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Guangdong Pharmaceutical University, No. 283 Jianghai Road, Haizhu District, Guangzhou, China.
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Spies G, Denckla CA, Mall S, Levin J, Seedat S, Nakasujja N, Kinyanda E. The relationship between cognitive change and physical health and behavioural outcomes in a Ugandan cohort of adults living with HIV - a longitudinal study. AIDS Care 2018; 31:803-808. [PMID: 30421989 DOI: 10.1080/09540121.2018.1545987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We investigated changes in cognitive function and physical health and behavioural outcomes (HIV disease progression, health-seeking behaviour, adherence to HIV medications and risky sexual behaviour) at baseline and 12 months later among 1126 Ugandan adults living with HIV. Overall, cognitive function improved from baseline to follow-up, except for gait speed, which was slower at follow-up compared to baseline. There were improvements in physical health and behavioural outcomes by follow-up, with greater improvements among individuals on ART compared to those not on ART. Change in gait speed over time significantly predicted risky sexual behaviours at follow-up. This is the first study to investigate the longitudinal relationships between cognitive function and health outcomes among Ugandan adults living with HIV and provide insights into the possible links between cognitive function and negative clinical and behavioural health outcomes in people living with HIV.
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Affiliation(s)
- G Spies
- a Department of Psychiatry, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - C A Denckla
- b Department of Epidemiology , Harvard T. H. Chan School of Public Health , Cambridge , MA , USA
| | - S Mall
- c Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa
| | - J Levin
- c Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences , University of the Witwatersrand , Johannesburg , South Africa.,d Statistical Section , MRC/UVRI Uganda Research Unit on AIDS , Entebbe , Uganda
| | - S Seedat
- a Department of Psychiatry, Faculty of Medicine and Health Sciences , Stellenbosch University , Cape Town , South Africa
| | - N Nakasujja
- e Department of Psychiatry , Makerere University , Kampala , Uganda
| | - E Kinyanda
- e Department of Psychiatry , Makerere University , Kampala , Uganda.,f Mental Health Project, MRC/LSHTM/UVRI and Senior Wellcome Trust Fellow , Uganda
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