Relationships with caregivers and mental health outcomes among adolescents living with HIV: a prospective cohort study in South Africa

"We did more than survive": lessons learned from studies of risk and resilience of young people growing up with HIV and mental health needs

Despite advances in HIV-treatment, adolescents and young adults (AYA) with HIV (AYAHIV) face myriad challenges. They are less likely than children and older adults to be virally suppressed and are at higher risk for mental health conditions compared to their peers who do not have HIV. AYA are also developing in the context of numerous biomedical, neurocognitive, and psychosocial developmental changes. Normative challenges during this time can be exacerbated by HIV and can result in significant physical and mental health problems. Yet, many AYAHIV have shown resilience with positive assets and resources and few health or mental health problems. Historically research has had a risk-focused approach to understanding AYAHIV needs. This paper discusses the rationale for a shift from a risk-focused only approach to one that examines AYAHIV needs from both a risk and resilience perspective. This paper presents: (1) epidemiological data on AYAHIV; (2) conceptual models for understanding both risk (e.g., poverty, stress, trauma, limited resources) and resilience/protective factors (e.g., family and peer support, future orientation, problem-solving skills); (3) global data examining risk and protective factors for physical and mental health challenges; and (4) promising interventions that incorporate elements of resilience to improve overall outcomes among AYAHIV.

Exploring the experiences of school-going children with HIV in Eswatini: A qualitative inquiry

BACKGROUND

 Infection by human immunodeficiency virus (HIV) is a major disease in children, affecting an estimated 1.8 million children and adolescents worldwide. Eswatini has the highest prevalence of HIV in the world. Only 76% of children in Eswatini are on anti-retroviral treatment.

AIM

 This study aimed to gain an in-depth understanding of the lived experience of school-going children with HIV in Eswatini. Being aware of these children's experiences can assist schools in supporting them.

SETTING

 The study was conducted in four primary health care facilities in Eswatini.

METHODS

 Employing a qualitative, exploratory, descriptive research design, 12 school-going children with HIV were interviewed through semi-structured face-to-face interviews. The data were coded, categorised and clustered into themes and sub-themes using Georgi's data analysis. Ethical considerations and measures to ensure trustworthiness were adhered to throughout the study.

RESULTS

 The findings revealed three themes: Experiences after HIV disclosure, experience of disclosure and discrimination, and experience of desire to fulfil educational needs. Six sub-themes were identified: A feeling of sadness and worry relating to knowledge of HIV diagnosis, a desire to disclose their status to their teachers but not to their peers, a need for protection against discrimination, a desire to learn, illness affecting their learning and expectation for teachers to be supportive in their educational needs.Conclusion and contribution: The findings of the study guided recommendations that may assist, the Eswatini Ministry of Health, schools, parents and caregivers, and siblings to support school-going children with HIV.

Identifying Adolescents at Highest Risk of ART Non-adherence, Using the World Health Organization-Endorsed HEADSS and HEADSS+ Checklists

Brief tools are necessary to identify adolescents at greatest risk for ART non-adherence. From the WHO's HEADSS/HEADSS+ adolescent wellbeing checklists, we identify constructs strongly associated with non-adherence (validated with viral load). We conducted interviews and collected clinical records from a 3-year cohort of 1046 adolescents living with HIV from 52 South African government facilities. We used least absolute shrinkage and selection operator variable selection approach with a generalized linear mixed model. HEADSS constructs most predictive were: violence exposure (aOR 1.97, CI 1.61; 2.42, p < 0.001), depression (aOR 1.71, CI 1.42; 2.07, p < 0.001) and being sexually active (aOR 1.80, CI 1.41; 2.28, p < 0.001). Risk of non-adherence rose from 20.4% with none, to 55.6% with all three. HEADSS+ constructs were: medication side effects (aOR 2.27, CI 1.82; 2.81, p < 0.001), low social support (aOR 1.97, CI 1.60; 2.43, p < 0.001) and non-disclosure to parents (aOR 2.53, CI 1.91; 3.53, p < 0.001). Risk of non-adherence rose from 21.6% with none, to 71.8% with all three. Screening within established checklists can improve identification of adolescents needing increased support. Adolescent HIV services need to include side-effect management, violence prevention, mental health and sexual and reproductive health.

Life quality, depression, and anxiety levels in parents of children with primary immunodeficiency

BACKGROUND

Primary immune deficiencies (PID) encompasses genetic disorders that result in recurrent infections and immune dysregulation, often increasing the risk of malignancies. The aim of this study is to determine the quality of life, depression, and anxiety in parents of children with PID.

METHODS

Various validated assessment tools, including the Beck Depression Inventory (BDI), State and Trait Anxiety Inventory (STAI), the 36-item Short Form Survey (SF-36), and a demographic form, were employed to gather data from 85 parents of 64 PID patients and 85 parents of 75 healthy children.

RESULTS

The findings reveal that parents of PID patients exhibited higher BDI, STAI-S, STAI-T, and fatigue subdomain of SF-36 (p = .013, p = .013, p = .027, p = .000). Both parents had lower energy levels than the normal population, but mothers experienced higher levels of anxiety and depression. PID mothers' had higher scores than fathers of PID patients with healthy children in BDI, STAI-S, and STAI-T (p = .002, p = .010, p = .001). Mothers of PID patients reported lower scores in RLEP, E/F, EWB, P, and GH compared to fathers (p = .009, p = .005, p = .034, p = .001, p = .003). Additionally, the study found that STAI-T influenced all subdimensions of HRQOL. These results highlight the substantial emotional and psychological burden placed on parents caring for children with PID.

CONCLUSION

The study underscores the importance of supporting caregivers to enhance the overall well-being of both parents and children with PID. Such support can potentially alleviate depression and anxiety levels among parents, ultimately improving their quality of life and aiding in the management of children with PID.

Associations of formal childcare use with health and human capital development for adolescent mothers and their children in South Africa: A cross-sectional study

AIM

This study aims to investigate associations of formal childcare with maternal and child outcomes in a large sample of adolescent mothers.

BACKGROUND

Forty percent of adolescent girls in Africa are mothers. Increasing evidence shows positive impacts of formal childcare use for adult women, but no known studies in the Global South examine associations for adolescent mothers and their children.

METHODS

We interviewed 1046 adolescent mothers and completed developmental assessments with their children (n = 1139) in South Africa's Eastern Cape between 2017 and 2019. Questionnaires measured childcare use, maternal and child outcomes and socio-demographic background variables. Using cross-sectional data, associations between formal childcare use and outcomes were estimated in multivariate multi-level analyses that accounted for individual-level and family-level clustering.

RESULTS

Childcare use was associated with higher odds of being in education or employment (AOR: 4.01, 95% CIs: 2.59-6.21, p < .001), grade promotion (AOR: 2.08, 95% CIs: 1.42-3.05, p < .001) and positive future ideation (AOR: 1.58, 95% CIs: 1.01-2.49, p = .047) but no differences in mental health. Childcare use was also associated with better parenting on all measures: positive parenting (AOR: 1.66, 95% CIs: 1.16-2.38, p = .006), better parental limit-setting (AOR: 2.00, 95% CIs: 1.37-2.93, p < .001) and better positive discipline (AOR: 1.77, 95% CIs: 1.21-2.59, p = .003). For the children, there were no differences in temperament or illness, but a significant interaction showed stronger associations between childcare use and better cognitive, language and motor scores with increasing child age (AOR: 5.04, 95% CIs: 1.59-15.96, p = .006).

CONCLUSIONS

Adolescent mothers might benefit substantially from formal childcare, but causal links need to be explored further. Childcare use was also associated with improved parenting and better child development over time, suggesting positive pathways for children. At an average of $9 per month, childcare provisions for adolescent mothers may offer low-cost opportunities to achieve high returns on health and human capital outcomes in Sub-Saharan African contexts.

Multisystemic supports and adolescent resilience to depression over time: A South African mixed methods study

In sub-Saharan countries, like South Africa, there is scant understanding of adolescent resilience to depression over time; the multisystemic resource combinations that support such resilience; and whether more diverse resource combinations yield better mental health dividends. In response, we conducted a longitudinal concurrent nested mixed methods study with 223 South African adolescents (mean age: 17.16 years, SD = 1.73; 64.60% girls; 81.60% Black). Using longitudinal mixture modeling, the quantitative study identified trajectories of depression and associations between trajectory membership and resource diversity. Using a draw-and-write methodology and reflexive thematic analyses, the qualitative study explored the resource diversity associated with each trajectory. Taken together, these studies identified four depression trajectories (Stable Low; Declining; Worsening; Chronic High) with varying resource diversity at baseline and over time. Resource diversity was inclusive of personal, relational, contextual, and culturally valued resources in both the Stable Low and Declining trajectories, with emphasis on relational supports. Personal resources were emphasized in the Worsening and Chronic High trajectories, and culturally valued and contextual resources de-emphasized. In summary, resource constellations characterized by within and across system diversity and cultural responsiveness are more protective and will be key to advancing sub-Saharan adolescent mental health.

Mental health and psychosocial interventions integrating sexual and reproductive rights and health, and HIV care and prevention for adolescents and young people (10-24 years) in sub-Saharan Africa: a systematic scoping review

Background

Interventions targeting combined sexual and reproductive health, Human Immunodeficiency Virus (HIV) management and mental health care in sub-Saharan Africa (SSA) are few. There is a need to address common determinants of poor mental, psychosocial and sexual and reproductive health and rights (SRHR) through multimodal and multipronged interventions for adolescents. The main objective of this study was to identify whether and how interventions targeting adolescent SRHR and HIV with a focus on pregnant and parenting adolescents in SSA include mental health components and how these components and their outcomes have been reported in the literature.

Methods

We carried out a two process scoping review approach between 01.04.2021 and 23.08.2022. In the first stage, we searched the PubMed database to identify studies focusing on adolescents and young people aged 10 to 24 from 2001 to 2021. We identified studies focusing on HIV and SRHR that had mental health and psychosocial aspects to the interventions. Our search yielded 7025 studies. Of these 38 were eligible based on our screening criteria that covered interventions, and on further scrutiny, using PracticeWise, an established coding system, we identified select problems and practices to provide a more granular assessment of how interventions developed for this context mapped on to specific problems. At this second stage process, we selected 27 studies for inclusion as actual interventional designs for further systematic scoping of their findings and we used the Joanna Briggs Quality Appraisal checklist to rate these studies. This review was registered within the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42021234627.

Findings

Our first set of findings is that when coding problems and solutions, mental health concerns were the least common category of problems targeted in these SRHR/HIV interventions; nevertheless, psychoeducation and cognitive behavioral strategies such as improved communication, assertiveness training, and informational support were offered widely. Of the 27 interventional studies included in the final review, 17 RCTs, 7 open trials, and 3 mixed designs, represented nine countries of the 46 countries in SSA. Intervention types included peer, community, family, digital, and mixed modality interventions. Eight interventions focused on caregivers and youth. Social or community ecology associated problems (being an orphan, sexual abuse, homelessness, negative cultural norms) were the most common risk factors and were more frequent than medical issues associated with HIV exposure. Our findings highlight the relevance and centrality of social issues related to adolescent mental and physical health along with the need to strengthen multimodal interventions along the lines of problems we have identified in our review.

Interpretation

Combined interventions jointly addressing adolescent SRHR, HIV, and mental health have been relatively understudied, despite evidence that adverse social and community factors are rampant in this population.

Funding

MK was funded by Fogarty International CenterK43 TW010716-05 and lead the initiative.

Individual-, Interpersonal- and Institutional-Level Factors Associated with HIV Stigma Among Youth in Kenya

HIV stigma remains a barrier in achieving optimal HIV treatment. We studied the prevalence and predictors of HIV stigma among adolescents and youth with HIV (AYWHIV) ages 15-24 years in Western Kenya. Of 1011 AYWHIV, 69% were female with a median age of 18 years. Most (59%) attended adolescent clinic days, and 40% attended support groups. One-quarter (27%) had experienced physical, 18% emotional, and 7% sexual violence. The majority of AYWHIV (88%) reported disclosure concerns, 48% reported perceived community stigma, 36% experienced, and 24% internalized stigma. Compared to AYWHIV attending adolescent clinics, those in general/adult clinics had higher internalized stigma. Similarly, having dropped out of school was associated with higher internalized stigma. AYWHIV in sexual relationships had higher experienced stigma and disclosure concerns. Lastly, exposure to violence was associated with higher experienced, internalized, perceived community stigma and disclosure concerns. These risk factors can be targeted when developing stigma-prevention interventions.

An economic incentive package to support the wellbeing of caregivers of adolescents living with HIV during the COVID-19 pandemic in South Africa: a feasibility study protocol for a pilot randomised trial

BACKGROUND

The mental and financial strain linked to unpaid caregiving has been amplified during the COVID-19 pandemic. In sub-Saharan Africa, carers of adolescents living with HIV (ALHIV) are critical for maintenance of optimum HIV treatment outcomes. However, the ability of caregivers to provide quality care to ALHIV is undermined by their ability to maintain their own wellbeing due to multiple factors (viz. poverty, stigma, lack of access to social support services) which have been exacerbated by the COVID-19 pandemic. Economic incentives, such as cash incentives combined with SMS reminders, have been shown to improve wellbeing. However, there is a lack of preliminary evidence on the potential of economic incentives to promote caregiver wellbeing in this setting, particularly in the context of a pandemic. This protocol outlines the design of a parallel-group pilot randomised trial comparing the feasibility and preliminary effectiveness of an economic incentive package versus a control for improving caregiver wellbeing.

METHODS

Caregivers of ALHIV will be recruited from public-sector HIV clinics in the south of the eThekwini municipality, KwaZulu-Natal, South Africa. Participants will be randomly assigned to one of the following groups: (i) the intervention group (n = 50) will receive three cash payments (of ZAR 350, approximately 23 USD), coupled with a positive wellbeing message over a 3-month period; (ii) the control group (n = 50) will receive a standard message encouraging linkage to health services. Participants will be interviewed at baseline and at endline (12 weeks) to collect socio-demographic, food insecurity, health status, mental health (stigma, depressive symptoms) and wellbeing data. The primary outcome measure, caregiver wellbeing, will be measured using the CarerQoL instrument. A qualitative study will be conducted alongside the main trial to understand participant views on participation in the trial and their feedback on study activities.

DISCUSSION

This study will provide scientific direction for the design of a larger randomised controlled trial exploring the effects of an economic incentive for improving caregiver wellbeing. The feasibility of conducting study activities and delivering the intervention remotely in the context of a pandemic will also be provided.

TRIAL REGISTRATION

PACTR202203585402090. Registry name: Pan African Clinical Trials Registry (PACTR); URL: https://pactr.samrc.ac.za/ ; Registration. date: 24 March 2022 (retrospectively registered); Date first participant enrolled: 03 November 2021.

Economic Well-being and Associated Mediating Pathways to Improved Antiretroviral Therapy Adherence Among Adolescents Living With HIV: A Prospective Cohort Study in South Africa

BACKGROUND

Adolescents living with HIV exhibit lower levels of adherence to antiretroviral therapy (ART) than other age groups. Poverty is a key barrier to ART adherence. This study aims at understanding how alleviating poverty through structural and internal pathways can help increase ART adherence among adolescents.

SETTING

Eastern Cape province, South Africa.

METHODS

One thousand forty-six adolescents living with HIV were recruited from 53 public health care facilities and interviewed at 3 data collection waves with a retention rate of 89% and a mortality rate of 3%. Data were collected by face-to-face, device-assisted interviews. Hybrid probit regressions and a structural equation path analysis were used to estimate the association between poverty reduction (increased access to basic necessities) and the pathways by which it could improve ART adherence.

RESULTS

Self-reported ART adherence ranged from an average of 66% (n = 615) at baseline to 75% (n = 700) in the last wave. Within-person and between-person improvements in economic well-being were associated with significant increases in adolescent ART adherence. On average, adolescents with access to 3 additional basic needs experienced a 4 percentage-point increase in the probability of ART adherence. Structural pathways to improved ART adherence included participants having enough money to travel to the clinic and sufficient food to eat when taking medication. Internal pathways included improved psychological well-being and reduced internalized HIV stigma.

CONCLUSION

Poverty reduction programs such as HIV-sensitive social protection can address structural and psychological pathways to increase ART adherence among economically disadvantaged adolescents by incentivizing demand-side interventions and the provision of quality essential services.

A qualitative investigation of facilitators and barriers to DREAMS uptake among adolescents with grandparent caregivers in rural KwaZulu-Natal, South Africa

Adolescents with grandparent caregivers have experienced challenges including the death of one or both parents due to HIV in sub-Saharan Africa. They may be left out of existing HIV prevention interventions targeting parents and children. We investigated the facilitators and barriers to DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) programme uptake among adolescents with grandparent caregivers across different levels of the socio-ecological model in rural South Africa. Data were collected in three phases (October 2017 to September 2018). Adolescents (13-19 years old) and their grandparent caregivers (≥50 years old) (n = 12) contributed to repeat in-depth interviews to share their perceptions and experiences regarding adolescents' participation in DREAMS. Data were triangulated using key informant interviews with DREAMS intervention facilitators (n = 2) to give insights into their experiences of delivering DREAMS interventions. Written informed consent or child assent was obtained from all individuals before participation. All data were collected in isiZulu and audio-recorded, transcribed verbatim and translated into English. Thematic and dyadic analysis approaches were conducted guided by the socio-ecological model. Participation in DREAMS was most effective when DREAMS messaging reinforced existing norms around sex and sexuality and when the interventions improved care relationships between the adolescents and their older caregivers. DREAMS was less acceptable when it deviated from the norms, raised SRH information that conflicts with abstinence and virginity, and when youth empowerment was perceived as a potential threat to intergenerational power dynamics. While DREAMS was able to engage these complex families, there were failures, about factors uniquely critical to these families, such as in engaging children and carers with disabilities and failure to include adolescent boys in some interventions. There is a need to adapt HIV prevention interventions to tackle care relationships specific to adolescent-grandparent caregiver communication.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

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.

Stigma and mental health challenges among adolescents living with HIV in selected adolescent-specific antiretroviral therapy clinics in Zomba District, Malawi

BACKGROUND

Of the 1.8 million adolescents between the ages of 10 and 19 living with HIV globally in 2020; approximately 1.5 million of these live in sub-Saharan Africa. These adolescents living with HIV (ALHIV) are at higher risk of experiencing mental health problems than those without; in Malawi, 18.9% have a depressive disorder. ALHIV can face numerous psychosocial challenges, but little is known about how ALHIV in Malawi perceive these stressors. Understanding psychosocial challenges of ALHIV is a key step in ensuring good mental health care. The aim of this study was to assess the psychosocial challenges faced by ALHIV attending adolescent-specific ART program in Zomba, Malawi.

METHODS

Between April and May 2019, we engaged a purposive sample of ALHIV ages 12-18 (n = 80) in a series of eight focus groups drawing from four Teen Clubs linked to an adolescent-specific ART program. Data were analyzed inductively and deductively to identify themes related to ALHIV psychosocial experiences.

RESULTS

Two themes that emerged from the study include: 1) stigma and discrimination within communities and families; 2) non-adherence to medications. HIV-related stigma was associated with increased psychological distress; physical and emotional/verbal abuse; low social support, isolation, and a feeling of rejection; and risky health behaviors such as medication hiding and non-adherence to ART. Discriminatory actions were manifested in a form of being given separate utensils for their meals and mistreatment at school. Furthermore, some parents did not allow their children to play with the participants out of fear that HIV transmission.

CONCLUSIONS

Stigma and discrimination are overlooked potential barriers to HIV treatment and care. If HIV services are to effectively meet ALHIVs' needs, mental health interventions are needed to prevent and manage depression and improve adherence to ART. These findings highlight the crucial need to develop culturally relevant mental interventions aimed at helping ALHIV to cope with these diverse challenges.

High Prevalence of Mental Health Disorders in Adolescents and Youth Living with HIV: An Observational Study from Eight Health Services in Sofala Province, Mozambique

Adolescent mental health (MH) is a significant global health concern, which is extremely relevant when referring to adolescents and youth living with HIV (AYHIV). In Mozambique, ∼52% of the population is <18 years and the country has the world's eighth highest HIV prevalence (insert citation). We performed an observational study to evaluate anxiety, depression, post-traumatic stress disorder (PTSD) and alcohol-drug abuse in adolescents and youth assessing health services in Sofala Province, Mozambique. From November 20, 2019, to November 20, 2021, all adolescents and youth (10-24 years) accessing one of the psychological services offered at 8 Servicios Amigos dos Adolescentes (SAAJ) of the Sofala Province were screened by a psychologist using the following standardized tools: Generalized Anxiety Disorder-7 (GAD-7) for anxiety, Patient Health Questionnaire-9 (PHQ-9) for depression, Primary Care PTSD Screen for DSM-5 (PC-PTSD-5) for PTSD, and Cut down, Annoyed, Guilty, and Eye-opener Adapted to Include Drugs (CAGE-AID) for alcohol-drug abuse. Overall, 2108 adolescents and youth were included in the study (63% female, median age: 19 years). Of them, 1096 (52%) were HIV positive. AYHIV had higher scores at the four tools tested and for concomitant MH disorders (GAD-7, PHQ-9, PTSD-5, and CAGE). The multivariable logistic regressions showed a greater probability to be GAD-7 > 10 for women, [adjusting odds ratio (AOR): 1.46, 95% confidence interval (CI): 1.01-2.10], for workers (AOR: 2.18, 95% CI: 1.12-4.23) and people living with HIV (AOR: 1.78, 95% CI: 1.25-2.54). Higher values of CAGE (≥2) and PTSD (≥3) seemed to be associated only with HIV-positive status (AOR: 4.87, 95% CI: 3.72-6.38 and AOR: 1.73, 95% CI: 1.28-237). These data further reinforce the urgent need for a global health policy action with focused intervention on MH in AYHIV patients.

Adolescent Motherhood and HIV in South Africa: Examining Prevalence of Common Mental Disorder

The mental health of adolescents (10–19 years) remains an overlooked global health issue, particularly within the context of syndemic conditions such as HIV and pregnancy. Rates of pregnancy and HIV among adolescents within South Africa are some of the highest in the world. Experiencing pregnancy and living with HIV during adolescence have both been found to be associated with poor mental health within separate explorations. Yet, examinations of mental health among adolescents living with HIV who have experienced pregnancy/parenthood remain absent from the literature. As such, there exists no evidence-based policy or programming relating to mental health for this group. These analyses aim to identify the prevalence of probable common mental disorder among adolescent mothers and, among adolescents experiencing the syndemic of motherhood and HIV. Analyses utilise data from interviews undertaken with 723 female adolescents drawn from a prospective longitudinal cohort study of adolescents living with HIV (n = 1059) and a comparison group of adolescents without HIV (n = 467) undertaken within the Eastern Cape Province, South Africa. Detailed study questionnaires included validated and study specific measures relating to HIV, adolescent motherhood, and mental health. Four self-reported measures of mental health (depressive, anxiety, posttraumatic stress, and suicidality symptomology) were used to explore the concept of likely common mental disorder and mental health comorbidities (experiencing two or more common mental disorders concurrently). Chi-square tests (Fisher’s exact test, where appropriate) and Kruskal Wallis tests were used to assess differences in sample characteristics (inclusive of mental health status) according to HIV status and motherhood status. Logistic regression models were used to explore the cross-sectional associations between combined motherhood and HIV status and, likely common mental disorder/mental health comorbidities. 70.5% of participants were living with HIV and 15.2% were mothers. 8.4% were mothers living with HIV. A tenth (10.9%) of the sample were classified as reporting a probable common mental disorder and 2.8% as experiencing likely mental health comorbidities. Three core findings emerge: (1) poor mental health was elevated among adolescent mothers compared to never pregnant adolescents (measures of likely common mental disorder, mental health comorbidities, depressive, anxiety and suicidality symptoms), (2) prevalence of probable common mental disorder was highest among mothers living with HIV (23.0%) compared to other groups (Range:8.5–12.8%; Χ² = 12.54, p = 0.006) and, (3) prevalence of probable mental health comorbidities was higher among mothers, regardless of HIV status (HIV & motherhood = 8.2%, No HIV & motherhood = 8.2%, Χ² = 14.5, p = 0.002). Results identify higher mental health burden among adolescent mothers compared to never-pregnant adolescents, an increased prevalence of mental health burden among adolescent mothers living with HIV compared to other groups, and an elevated prevalence of mental health comorbidities among adolescent mothers irrespective of HIV status. These findings address a critical evidence gap, highlighting the commonality of mental health burden within the context of adolescent motherhood and HIV within South Africa as well as the urgent need for support and further research to ensure effective evidence-based programming is made available for this group. Existing antenatal, postnatal, and HIV care may provide an opportunity for mental health screening, monitoring, and referral.

Barriers and facilitators to implementing the HEADSS psychosocial screening tool for adolescents living with HIV/AIDS in teen club program in Malawi: health care providers perspectives

BACKGROUND

Adolescents living with HIV (ALHIV) are at high risk of experiencing mental health problems. Depression is a major contributor to the burden of HIV-related disease amongst ALHIV and is significantly linked to non-adherence to anti-retroviral therapy (ART), yet it is under-recognized. In 2015, the Baylor College of Medicine International Pediatric AIDS Initiative (BIPAI) recommended that the psychosocial screening tool Home, Education, Activities, Drugs, Sexuality, Suicide/Depression (HEADSS) be used to screen ALHIV in Malawi who were part of an adolescent antiretroviral therapy program termed "Teen Club". However, the HEADSS tool has been substantially under-utilized. This study assessed barriers and facilitators to implementing HEADSS for ALHIV attending Teen Club Program in four selected health facilities in Malawi.

METHODS

We conducted a qualitative study using semi-structured interviews at four program sites (one district hospital and one health center each in two districts) between April and May 2019. Twenty key informants were purposively selected to join this study based on their role and experiences. We used the five domains of the Consolidated Framework for Implementation Research (CFIR) to guide the development of the interview guides, analysis and interpretation of results.

RESULTS

Barriers included inadequate planning for integration of the HEADSS approach; concerns that the HEADSS tool was too long, time consuming, lacked appropriate cultural context, and increased workload; and reports by participants that they did not have knowledge and skills to screen ALHIV using this tool. Facilitators to implementing the screening were that health care providers viewed screening as a guide to better systematic counselling, believed that screening could build better client provider relationship, and thought that it could fit into the existing work practice since it is not complex.

CONCLUSIONS

A culturally adapted screening tool, especially one that can be used by non-clinicians such as lay health workers, would improve the ability to address mental health needs of ALHIV in many primary care and social service settings where resources for professional mental health staff are limited. These findings are a springboard for efforts to culturally adapt the HEADSS screening tool for detection of mental and risky behaviors among ALHIV attending ART program in Malawi.

Adolescent Mental Health Resilience and Combinations of Caregiver Monitoring and Warmth: A Person-centred Perspective

Caregiver monitoring and warmth have protective mental health effects for adolescents, including vulnerable adolescents. However, combinations of the aforesaid parenting behaviours and their relationship with adolescent mental health are underexplored, especially among younger and older South African (SA) adolescents challenged by structural disadvantage. Hence, the purpose of this study was to investigate unique profiles of caregiver monitoring and warmth and their associations with depression and conduct problems as reported by younger and older adolescents from disadvantaged SA communities. Latent profile and linear regression analyses were used to examine cross-sectional survey data generated by 891 adolescents from two disadvantaged SA communities (62.2% aged 13-17 [average age: 16.13]; 37.5% aged 18-24 [average age: 20.62]). Two profiles emerged. The first, i.e. substantial caregiver warmth and some monitoring, was associated with younger and older adolescent reports of statistically significantly fewer symptoms of depression and conduct problems. The second, i.e. caregiver monitoring without much warmth, was associated with significantly more symptoms of depression or conduct problems among younger and older adolescents. Traditional gender effects (i.e. higher depression symptoms among girls; higher conduct problem symptoms among boys) were amplified when caregiver monitoring was combined with low warmth. In short, protecting the mental health of younger and older adolescents from disadvantaged communities requires higher levels of caregiver warmth combined with moderate levels of caregiver supervision. Because stressors associated with disadvantaged communities jeopardise warm parenting, supporting caregiver resilience to those stressors is integral to supporting adolescent mental health.

Prevalence of psychotic-like experiences and its predictors among early adolescents from rural areas in Indonesia

Background: Psychotic symptoms are present in a wide range of both clinical and non-clinical populations. Psychotic symptoms in adolescents often take the form of psychotic-like experiences (PLEs), which are considered a risk factor for numerous serious mental illnesses. Socioeconomic disadvantages are across rural areas, and poverty is known as the third most important risk factor of PLEs. However, there have been limited studies on PLEs which focus on populations in rural areas.Objective: The aim of this study was to assess the prevalence of PLEs and investigate their predictors among early adolescents living in rural areas.Method: Data from 629 early adolescents from two rural areas in Indonesia were analysed using descriptive statistics to determine the prevalence of PLEs. Multiple logistic regression analysis was used to assess the predictors of PLEs. This was a school-based cross-sectional study, and data were collected using a paper questionnaire.Results: The results showed that the prevalence of PLEs among early adolescents in rural areas is 24.5%. Four significant predictors of PLEs were identified after controlling for sex: emotional problems, age, the number of caregivers in daily life, and psychological well-being.