Prevalence, risk and protective indicators of common mental disorders among young people living with HIV compared to their uninfected peers from the Kenyan coast: a cross-sectional study

Adults with Perinatally Acquired HIV; Emerging Clinical Outcomes and Data Gaps

In resourced settings, adults living with perinatally acquired HIV are approaching the 5th decade of life. Their clinical and psychological outcomes highlight potential future issues for the much larger number of adolescents growing up with HIV in sub-Saharan Africa, and will inform the development of appropriate healthcare services. Lifelong exposure to HIV, and increasingly to antiretroviral therapy throughout growth and development, contrasts with adults acquiring HIV in later life. This review describes the clinical outcomes for adults living with perinatally acquired HIV including post transition mortality, morbidity and retention in care. Rates of viral suppression, drug resistance and immunological function are explored. Co-morbidities focus on metabolic, cardiovascular, respiratory and bone health with quality-of-life data including neurocognitive functioning and mental health. Sexual and reproductive health including vaccine-preventable disease and the prevention of onward transmission to partners and infants are considered. The data gaps and future research questions to optimise outcomes for this emerging adult cohort are highlighted.

Generalized and COVID related anxiety as risk factors for health outcomes among adolescents with HIV during COVID-19 in Tanzania

The COVID-19 pandemic and associated prevention strategies caused widespread interruptions to care and treatment for people living with HIV. Adolescents living with HIV (AWHIV) were particularly vulnerable to poor mental and physical health during COVID-19. We assessed the burden of generalized and COVID-19-related anxiety and associations with adherence to HIV care and treatment and viral load suppression (VLS) among AWHIV during the peak of the COVID-19 pandemic in Tanzania.

Methods

This cross-sectional study was conducted among AWHIV aged 15-19 years attending 10 clinics in Dar es Salaam from April 2022-February 2023. Study participants completed a self-administered questionnaire including Generalized Anxiety Disorder (GAD), COVID-19-related anxiety, and other psychosocial and physical health and support measures. HIV visit adherence, viral load and sociodemographic data were abstracted from patient health records.Analysis:: Multivariable (MV) quasibinomial and logistic regression models examined associations of Generalized and COVID-19-related anxiety with visit adherence and HIV virologic suppression (HIV VL < 50 copies/mL). Data were analyzed using R software.

Results

658 AWHIV (52% male) were included in this analysis. Most (86%) had been on antiretroviral treatment (ART) for at least four years, 55% attended at least 75% of their scheduled clinic visits, and 78% were HIV virologically suppressed. The median GAD and COVID-19-related anxiety scores were 2 (IQR: 0-5, and 26 (IQR: 13-43; respectively. Only 2% scored moderate-severe generalized anxiety (score 10-21). We found no significant associations between COVID-19-related anxiety or GAD and visit adherence. Higher GAD was inversely associated with VLS (adjusted odds ratio (AOR): 0.89 (95% CI 0.81, 0.98)). Female gender and higher quality of physical life were significantly associated with VLS.

Conclusion

Low levels of generalized and COVID-19 related anxiety were reported among Tanzanian AWHIV. Integrating screening and management of generalized anxiety screening into HIV care for AWHIV could improve VLS among this population.

Navigating Life With HIV as an Older Adult on the Kenyan Coast: Perceived Health Challenges Seen Through the Biopsychosocial Model

Objectives: This study explores the perceptions of adults living with HIV aged ≥50 years (recognized as older adults living with HIV-OALWH), primary caregivers and healthcare providers on the health challenges of ageing with HIV at Kilifi, a low literacy setting on the coast of Kenya. Methods: We utilized the biopsychosocial model to explore views from 34 OALWH and 22 stakeholders on the physical, mental, and psychosocial health challenges of ageing with HIV in Kilifi in 2019. Data were drawn from semi-structured in-depth interviews, which were audio-recorded and transcribed. A framework approach was used to synthesize the data. Results: Symptoms of common mental disorders, comorbidities, somatic symptoms, financial difficulties, stigma, and discrimination were viewed as common. There was also an overlap of perceived risk factors across the physical, mental, and psychosocial health domains, including family conflicts and poverty. Conclusion: OALWH at the Kenyan coast are perceived to be at risk of multiple physical, mental, and psychosocial challenges. Future research should quantify the burden of these challenges and examine the resources available to these adults.

Adherence to antiretroviral therapy in people living with HIV with moderate or severe mental disorder

Human immunodeficiency virus (HIV) infection remains a serious public health concern, with an estimated 38 million people living with HIV (PLHIV). PLHIV are often affected by mental disorders at higher rate than the general population. One challenge in the control and prevention of new HIV infections is adherence to antiretroviral therapy (ART), with PLHIV with mental disorders having seemingly lower adherence than PLHIV without mental disorders. This cross-sectional study assessed adherence to ART in PLHIV with mental disorders who attended the Psychosocial Care Network health facilities in Campo Grande, Mato Grosso do Sul, Brazil, from January 2014 to December 2018. Data from health and medical databases were used to describe clinical-epidemiological profiles and adherence to ART. To assess the associated factors (potential risk or predisposing factors) with ART adherence, we used logistic regression model. Adherence was extremely low (16.4%). Factors associated with poor adherence were lack of clinical follow-up, particularly in middle-aged PLHIV. Other apparently associated factors were living on the streets and having suicidal ideation. Our findings reinforce the need for improvements in the care for PLHIV with mental disorders, especially in the integration between specialized mental health and infectious disease health facilities.

Alcohol use, suicidality and virologic non-suppression among young adults with perinatally acquired HIV in Thailand: a cross-sectional study

INTRODUCTION

Young adults with perinatally acquired HIV (YA-PHIV) are facing transitions to adult life. This study assessed health risk behaviours (including substance use), mental health, quality of life (QOL) and HIV treatment outcomes of Thai YA-PHIV.

METHODS

A cross-sectional study was conducted in Thai YA-PHIV aged 18-25 years who were enrolled in a prospective cohort study at five tertiary paediatric HIV care centres in Thailand. Study data were obtained through face-to-face interviews from November 2020 to July 2021. Assessments were performed for alcohol use (Alcohol Use Disorders Identification Test; AUDIT), smoking (Fagerstrom Test for Nicotine Dependence), drug/substance use (Drug Abuse Screening Test; DAST-10), depression (Patient Health Questionnaire for Adolescents; PHQ-A), anxiety (Generalized Anxiety Disorder; GAD-7) and QOL (World Health Organization QOL Brief-Thai). HIV treatment outcomes were extracted from the National AIDS Program database.

RESULTS

Of 355 YA-PHIV, 163 (46%) were males: their median age was 21.7 (interquartile range, IQR 20.2-23.5) years. There were 203 YA-PHIV (58%) who reported ever having sex; 141 (40%) were sexually active in the past 6 months, of whom 86 (61%) reported 100% condom use. Overall, 49 (14%) met the criteria for harmful alcohol use; 28 (7.9%) were alcohol dependent. Sixty (17%) were current smokers and 37 (11%) used drugs/substances. The frequency of moderate up to severe symptoms for depression was 18% and for anxiety was 9.7%. Their overall QOL was good in 180 (51%), moderate in 168 (47%) and poor in five (1.4%). There were 49 YA-PHIV (14%) with CD4 <200 cells/mm3 and 85 (24%) with virologic non-suppression (HIV-RNA >200 copies/ml). On multivariate analyses, the highest education at the primary to high school or vocational school levels (adjusted odds ratio [aOR] 2.02, 95% CI 1.40-3.95, p 0.04), harmful alcohol use (aOR 2.48, 95% CI 1.24-4.99, p 0.01), alcohol dependence (aOR 3.54, 95% CI 1.51-8.31, p <0.01) and lifetime suicidal attempt (aOR 2.66, 95% CI 1.11-6.35, p 0.03) were associated with non-suppression.

CONCLUSIONS

Regular screening for alcohol use and mental health, including suicidality, would be useful to identify YA-PHIV who need more intensive psychosocial support or referral services to ensure they can achieve and maintain a high QOL into adult life.

Comorbidity of mental ill-health in tuberculosis patients under treatment in a rural province of South Africa: a cross-sectional survey

OBJECTIVES

Tuberculosis (TB) remains prevalent despite the availability of effective anti-TB medications, and accumulating evidence suggests a high rate of mental disorders in people with TB. This is because TB and psychiatric disorders share several risk factors, such as poverty, homelessness and substance use disorder. Moreover, psychiatric comorbidities in patients with TB are associated with poor treatment outcomes. This study explored the psychiatric comorbidity and clinical correlates in individuals receiving TB treatment.

DESIGN

A cross-sectional survey over 10 months.

SETTING

Two primary care clinics at King Sabata Dalindyebo district, Mthatha, Eastern Cape, South Africa.

PARTICIPANT

Patients receiving TB treatment in the two clinics.

INTERVENTION

The Mini-International Neuropsychiatric Interview was used to screen for psychiatric disorders.

PRIMARY AND SECONDARY OUTCOME MEASURES

Rates of mental disorders in patients with TB over a 10-month period. Variation in rates by sex, employment status and HIV comorbidity.

RESULTS

In a sample of 197 participants, most patients were men (62%) and screened positive for a mental disorder (82%) with anxiety (48%), depression (38%) and substance use disorders (43%) being the most common psychiatric conditions. On average, individuals had 4 (SD 2) mental disorders. Females had higher rates of depression (p=0.005) and non-adherence to TB treatment (p=0.003), and alcohol use disorder was more common in males (p<0.001) and in those non-adherent to TB treatment. Additionally, low education levels and unemployment were associated with depressive and anxiety disorders (p<0.05).

CONCLUSIONS

Mental disorders are common in patients with TB, and mental health services need to be integrated into the management of patients with TB. Factors linked to mental disorders in this cohort, such as low education, gender and unemployment, may be useful for compiling a risk profile to help identify those with TB who may require more intensive support for their mental health.

Adaptation, acceptability and feasibility of Problem Management Plus (PM+) intervention to promote the mental health of young people living with HIV in Kenya: formative mixed-methods research

BACKGROUND

Problem Management Plus (PM+) is a psychological intervention that seeks to address common mental disorders among individuals exposed to adversity. Thus far, the potential for delivering PM+ by mobile phones has not been evaluated.

AIMS

To adapt PM+ for telephone delivery (ten weekly sessions of about 45 min each) and preliminarily evaluate its acceptability and feasibility with young people living with HIV (YLWH) in coastal Kenya.

METHOD

This was a mixed-method formative research. Qualitative data collection included consultations with stakeholders, conducting key informant interviews with HIV care providers and focus group discussions with potential end-users, i.e. YLWH. Moreover, brief exit interviews with recipients of the adapted PM+ were conducted. Quantitative acceptability and feasibility indicators and outcome measures were tracked/assessed during PM+ preliminary implementation involving 70 YLWH.

RESULTS

From the qualitative inquiries, the adapted PM+ emerged as contextually appropriate, acceptable and feasible for mobile phone delivery, despite some concerns around missing nonverbal cues and poor network connectivity. High recruitment (85%) and fair programme retention (69%) were observed. Intervention sessions over the telephone lasted 46 min on average (range 42-55 min). Preliminary feasibility data indicated that the adapted PM+ has the potential of reducing common mental disorders among YLWH from the Kenyan coast.

CONCLUSIONS

PM+ is acceptable and can feasibly be delivered via mobile phone to YLWH in coastal Kenya. This study sets the stage for a future fully powered, randomised controlled trial assessing the efficacy of the adapted PM+ in this or a similar setting.

Telling the story of intersectional stigma in HIV-associated Kaposi's sarcoma in western Kenya: a convergent mixed-methods approach

INTRODUCTION

The experience of stigma can be multifaceted for people with HIV and cancer. Kaposi's sarcoma (KS), one of the most common HIV-associated cancers in sub-Saharan Africa, often presents with visible skin lesions that may put people at risk for stigmatization. In this way, HIV-associated KS is unique, as people with KS can experience stigma associated with HIV, cancer, and skin disease simultaneously. The aim of this study is to characterize the intersectionality of HIV-related, cancer-related and skin disease-related stigma in people living with HIV and KS.

METHODS

We used a convergent mixed-methods approach nested within a longitudinal study of people with HIV-associated KS in western Kenya. Between February 2019 and December 2020, we collected quantitative surveys among all participants and conducted semi-structured interviews among a purposive sample of participants. Quantitative surveys were adapted from the abridged Berger HIV Stigma Scale to assess overall stigma, HIV-related stigma, cancer-related stigma, and skin disease-related stigma. Qualitative data were coded using stigma constructs from the Health Stigma and Discrimination Framework.

RESULTS

In 88 semi-structured interviews, stigma was a major barrier to KS diagnosis and treatment among people with HIV-associated KS. Participant's stories of stigma were dominated by HIV-related stigma, more than cancer-related or skin disease-related stigma. However, quantitative stigma scores among the 117 participants were similar for HIV-related (Median: 28.00; IQR: 28.0, 34.0), cancer-related (Median: 28.0; IQR: 28.0, 34.8), and skin disease-related stigma (Median: 28.0; IQR: 27.0, 34.0). In semi-structured interviews, cancer-related and skin disease-related stigma were more subtle contributors; cancer-related stigma was linked to fatalism and skin-related stigma was linked to visible disease. Participants reported resolution of skin lesions contributed to lessening stigma over time; there was a significant decline in quantitative scores of overall stigma in time since KS diagnosis (adjusted β = -0.15, p <0.001).

CONCLUSIONS

This study highlights the role mixed-method approaches can play in better understanding stigma in people living with both HIV and cancer. While HIV-related stigma may dominate perceptions of stigma among people with KS in Kenya, intersectional experiences of stigma may be subtle, and quantitative evaluation alone may be insufficient to understand intersectional stigma in certain contexts.

Prevalence of stressful life events and associations with symptoms of depression, anxiety, and post-traumatic stress disorder among people entering care for HIV in Cameroon

BACKGROUND

Exposure to stressors increases the risk of mental health disorders. People living with HIV (PLWH) are particularly affected by poor mental health which can contribute to adverse HIV treatment outcomes.

METHODS

We estimated the prevalence of recent stressful life events (modified Life Events Survey) among a cohort of PLWH entering HIV care at three public health care facilities in Cameroon and quantified the association of seven types of stressful life events with symptoms of depression (Patient Health Questionnaire-9 scores>9), anxiety (General Anxiety Disorder-7 scores>9), and PTSD (PTSD Checklist for DSM-5 scores>30) using separate log-binomial regression models.

RESULTS

Of 426 PLWH enrolling in care, a majority were women (59%), in relationships (58%), and aged 21 to 39 years (58%). Recent death of a family member (39%) and severe illness of a family member (34%) were the most commonly reported stressful life events. In multivariable analyses, more stressful life event types, a negative relationship change, death or illness of a friend/family member, experience of violence, work-related difficulties, and feeling unsafe in one's neighborhood were independently associated with at least one of the mental health outcomes assessed. The greatest magnitude of association was observed between work-related difficulties and PTSD (adjusted prevalence ratio: 3.1; 95% confidence interval: 2.0-4.8).

LIMITATIONS

Given the design of our study, findings are subject to recall and social desirability bias.

CONCLUSIONS

Stressful life events were common among this population of PLWH entering care in Cameroon. Evidence-based interventions that improve coping, stress management, and mental health are needed.

HIV virological non-suppression is highly prevalent among 18- to 24-year-old youths on antiretroviral therapy at the Kenyan coast

BACKGROUND

In sub-Saharan Africa, data on virologic outcomes of young people living with HIV (YLWH) enrolled on antiretroviral therapy (ART) remains scarce. In this study, we describe the prevalence of HIV virological non-suppression (VNS) and its associated factors among YLWH aged 18-24 years from the Kenyan coast.

METHODS

Data were analyzed for 384 YLWH who participated in a larger cross-sectional study conducted between November 2018 and September 2019 in two counties at the Kenyan coast (Kilifi and Mombasa). Descriptive statistics were used to summarize sample characteristics and logistic regression was used for statistical modeling of factors associated with VNS. In this study, VNS was defined as plasma viral load ≥ 1000 copies/mL.

RESULTS

Among these YLWH with a mean age of 20.7 years (SD = 2.2); 55.5% females, the overall prevalence of VNS was 32.0% (95% Confidence interval (95% CI): 27.5, 36.9%). In the multivariable logistic regression analysis, being from a largely rural setting (adjusted Odds Ratio (aOR) 1.73, 95% CI 1.10, 2.71; p = 0.02), underweight (aOR 1.87, 95% CI 1.16, 3.01; p = 0.01) and low self-reported ART adherence (aOR 2.83, 95% CI 1.34, 6.00; p = 0.01) were significantly associated with higher odds of VNS in YLWH.

CONCLUSIONS

In this study, high levels of VNS were observed among YLWH and this was significantly associated with rural residency, nutritional and ART adherence problems. ART adherence counselling and nutritional support and education should be intensified in this setting targeting YLWH residing mostly in rural areas. Given the high frequency of VNS, there is need to closely monitor viral load and profile HIV drug resistance patterns in youths from the Kenyan coast with confirmed virologic failure. The latter will help understand whether drug resistance also contributes to poor viral suppression in addition to, or exclusive of suboptimal ART adherence.

Voices from the Youth in Kenya Addressing Mental Health Gaps and Recommendations

Studies including adolescents and young people (AYP) enhance the relevance of research results, benefit stakeholders, and inform future research. There exists a mental health gap in services for AYP living in low and middle-income countries. This study aims to identify mental health challenges faced by adolescents and young people in Kenya, develop practical recommendations to mitigate these issues, and reduce the mental health burden among this population. We convened an AYP-led meeting that involved 41 participants. The meeting objectives were to (1) identify efforts to support existing national and regional strategic priorities and review goals for addressing mental health needs among AYPs, (2) develop immediate action plans for strengthened mental health services, (3) review and strengthen country-level coordination mechanisms, and (4) identify how participating county experiences can inform mental health services in Kenya. Ministry of Health (MoH) officials from national and county levels, academic experts, and implementing partner agencies involved in mental health services participated in the meeting. The team, including AYP representatives, identified various mental health challenges among the AYA and recommended interventions aimed towards improving their mental health situation in the country. The challenges were clustered into three themes and comprehensively reviewed to establish the precipitating factors to mental health outcomes among AYPs in Kenya and provide recommendations. The themes included (1) legislative, (2) service provider/Ministry of Health, and (3) adolescent/individual-level factors. To bridge the mental health gap in the country and scale up mental health outcomes, the stakeholders recommended interventions within the context of the three clusters. The key suggestions included an increase in insurance financing, acceleration of community health interventions, the establishment of adolescent-friendly spaces, the training of adolescent youth champions, interactive service provision models, implementation of the existing mental health policies and structures, the development of comprehensive assessment tools, well equipped mental health departments in health facilities, the enhancement of telehealth services and digital villages, the mobilization of a functional mental health response team, and the development of a mental health database.

Psychosocial and mental health challenges faced by emerging adults living with HIV and support systems aiding their positive coping: a qualitative study from the Kenyan coast

BACKGROUND

In sub-Saharan Africa, there is little data on the challenges faced by young people living with HIV transitioning into adult life. Adapting the socio-ecological framework, this qualitative study investigated the challenges faced by emerging adults living with HIV from a rural Kenyan setting. Additionally, the study explored support systems that aid positive coping among these young adults.

METHODS

In April 2018, in-depth interviews were conducted with a convenience sample of 22 young adults living with HIV (12 females), 18-24 years old, from rural Kilifi, coast of Kenya. Data were analyzed thematically using NVIVO 11 software.

RESULTS

Young adults living with HIV from this setting face various challenges at different levels of the social ecosystem. At the individual level, key challenges they reported included acceptance of HIV positive status, antiretroviral adherence, economic burden associated with access to healthcare, building an intimate relationship, mental health problems, and HIV status disclosure. At the family level, death of parents, poverty, and being unaccepted were the commonly mentioned challenges. At the community level, socialization difficulties and long waiting time at the HIV clinic were highlighted. HIV stigma and discrimination were frequently reported across the different levels. Economic independence, social support (from families, friends, organizations, healthcare providers and peer meetings), and reliance on spirituality aided positive coping among these young adults amidst the challenges of living with HIV.

CONCLUSIONS

In this rural setting, emerging adults living with HIV face various challenges at the individual, family, and community level, some of which are cross-cutting. Our findings underscore the need for designing multi-level youth-friendly interventions that can address modifiable challenges encountered by emerging adults living with HIV in this and similar settings. Such interventions should incorporate appropriate context-specific support structures that may help these young people smoothly transit into adult life.

Psychometric Properties of the Berger HIV Stigma Scale: A Systematic Review

Addressing HIV-related stigma requires the use of psychometrically sound measures. However, despite the Berger HIV stigma scale (HSS) being among the most widely used measures for assessing HIV-related stigma, no study has systematically summarised its psychometric properties. This review investigated the psychometric properties of the HSS. A systematic review of articles published between 2001 and August 2021 was undertaken (CRD42020220305) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additionally, we searched the grey literature and screened the reference lists of the included studies. Of the total 1241 studies that were screened, 166 were included in the review, of which 24 were development and/or validation studies. The rest were observational or experimental studies. All the studies except two reported some aspect of the scale's reliability. The reported internal consistency ranged from acceptable to excellent (Cronbach's alpha ≥ 0.70) in 93.2% of the studies. Only eight studies reported test-retest reliability, and the reported reliability was adequate, except for one study. Only 36 studies assessed and established the HSS's validity. The HSS appears to be a reliable and valid measure of HIV-related stigma. However, the validity evidence came from only 36 studies, most of which were conducted in North America and Europe. Consequently, more validation work is necessary for more precise insights.

Alcohol and illicit drug use among young people living with HIV compared to their uninfected peers from the Kenyan coast: prevalence and risk indicators

BACKGROUND

In sub-Saharan Africa, there is paucity of research on substance use patterns among young people living with HIV (YLWH). To address the gap, we sought to: i) determine the prevalence of substance use, specifically alcohol and illicit drug use, among YLWH compared to their HIV-uninfected peers; ii) investigate the independent association between young people's HIV infection status and substance use; iii) investigate the risk indicators for substance use among these young people.

METHODS

Between November 2018 and September 2019, a cross-sectional study was conducted at the Kenyan coast recruiting 819 young people aged 18-24 years (407 HIV-positive). Alcohol and drug use disorders identification tests (AUDIT and DUDIT) were administered via audio computer-assisted self-interview alongside other measures. Logistic regression was used to determine substance use risk indicators.

RESULTS

The point prevalence of current substance use was significantly lower among YLWH than HIV-uninfected youths: current alcohol use, 13% vs. 24%, p <  0.01; current illicit drug use, 7% vs. 15%, p <  0.01; current alcohol and illicit drug use comorbidity, 4 vs. 11%, p <  0.01. Past-year prevalence estimates for hazardous substance use were generally low among young people in this setting (< 10%) with no significant group differences observed. Being HIV-positive independently predicted lower odds of current substance use, but not hazardous substance use. There was overlap of some risk indicators for current substance use between young people with and without HIV including male sex, khat use and an experience of multiple negative life events, but risk indicators unique to either group were also identified. Among YLWH, none of the HIV-related factors was significantly associated with current substance use.

CONCLUSIONS

At the Kenyan coast, substance use is a reality among young people. The frequency of use generally appears to be low among YLWH compared to the HIV-uninfected peers. Substance use prevention initiatives targeting young people, regardless of HIV infection status, are warranted in this setting to avert their potential risk for developing substance use disorders, including dependence. The multifaceted intrapersonal and interpersonal factors that place young people at risk of substance use need to be addressed as part of the substance use awareness and prevention initiatives.