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Hu A, Zaongo SD, Harypursat V, Wang X, Ouyang J, Chen Y. HIV-associated neurocognitive disorder: key implications of the microbiota-gut-brain axis. Front Microbiol 2024; 15:1428239. [PMID: 39155987 PMCID: PMC11327151 DOI: 10.3389/fmicb.2024.1428239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 07/23/2024] [Indexed: 08/20/2024] Open
Abstract
HIV-associated neurocognitive disorder (HAND) is now recognized to be relatively common in people living with HIV (PLWH), and remains a common cause of cognitive impairment. Unfortunately, the fundamental pathogenic processes underlying this specific outcome of HIV infection have not as yet been fully elucidated. With increased interest in research related to the microbiota-gut-brain axis, the gut-brain axis has been shown to play critical roles in regulating central nervous system disorders such as Alzheimer's disease and Parkinson's disease. PLWH are characterized by a particular affliction, referred to as gut-associated dysbiosis syndrome, which provokes an alteration in microbial composition and diversity, and of their associated metabolite composition within the gut. Interestingly, the gut microbiota has also been recognized as a key element, which both positively and negatively influences human brain health, including the functioning and development of the central nervous system (CNS). In this review, based on published evidence, we critically discuss the relevant interactions between the microbiota-gut-brain axis and the pathogenesis of HAND in the context of HIV infection. It is likely that HAND manifestation in PLWH mainly results from (i) gut-associated dysbiosis syndrome and a leaky gut on the one hand and (ii) inflammation on the other hand. In other words, the preceding features of HIV infection negatively alter the composition of the gut microbiota (microbes and their associated metabolites) and promote proinflammatory immune responses which singularly or in tandem damage neurons and/or induce inadequate neuronal signaling. Thus, HAND is fairly prevalent in PLWH. This work aims to demonstrate that in the quest to prevent and possibly treat HAND, the gut microbiota may ultimately represent a therapeutically targetable "host factor."
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Affiliation(s)
- Aizhen Hu
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Silvere D. Zaongo
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Vijay Harypursat
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
| | - Xin Wang
- Phase I Clinical Trial Center, Chonggang General Hospital, Chongqing, China
| | - Jing Ouyang
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
| | - Yaokai Chen
- Clinical Research Center, Chongqing Public Health Medical Center, Chongqing, China
- Department of Infectious Diseases, Chongqing Public Health Medical Center, Chongqing, China
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Grimes KEL, Ebasone PV, Dzudie A, Nash D, Wainberg ML, Pence BW, Barrington C, Pefura E, Yotebieng M, Anastos K, Nsame D, Ajeh R, Nyenti A, Parcesepe AM. Factors influencing integration of mental health screening and treatment at HIV clinic settings in Cameroon: a qualitative study of health providers' perspectives. BMC Health Serv Res 2024; 24:519. [PMID: 38658992 PMCID: PMC11044447 DOI: 10.1186/s12913-024-10775-w] [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: 05/31/2023] [Accepted: 02/23/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Mental disorders are common among people with HIV (PWH) and are associated with poor HIV outcomes. Despite high unmet mental health needs among PWH, use of evidence-based mental health screening and treatment protocols remains limited at HIV treatment facilities across low-resource settings. Integrating mental health services into HIV care can reduce this gap. This study's objective was to explore factors that influence integration of mental health screening and treatment into HIV clinics in Cameroon. METHODS We analyzed 14 in-depth interviews with clinic staff supporting PWH at three urban HIV treatment clinics in Cameroon. Interviews focused on current processes, barriers and facilitators, and types of support needed to integrate mental health care into HIV care. Interviews were recorded and transcribed. French transcripts were translated into English. We used thematic analysis to identify factors that influence integration of mental health screening and treatment into HIV care in these settings. Ethical review boards in the United States and Cameroon approved this study. RESULTS Respondents discussed a lack of standardized mental health screening processes in HIV treatment facilities and generally felt ill-equipped to conduct mental health screening. Low community awareness about mental disorders, mental health-related stigma, limited physical space, and high clinic volume affected providers' ability to screen clients for mental disorders. Providers indicated that better coordination and communication were needed to support client referral to mental health care. Despite these barriers, providers were motivated to screen clients for mental disorders and believed that mental health service provision could improve quality of HIV care and treatment outcomes. All providers interviewed said they would feel more confident screening for mental disorders with additional training and resources. Providers recommended community sensitization, training or hiring additional staff, improved coordination to manage referrals, and leadership buy-in at multiple levels of the health system to support sustainable integration of mental health screening and treatment into HIV clinics in Cameroon. CONCLUSIONS Providers reported enthusiasm to integrate mental health services into HIV care but need more support and training to do so in an effective and sustainable manner.
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Affiliation(s)
- Kathryn E L Grimes
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | | | - Anastase Dzudie
- Clinical Research Education Networking and Consultancy, Yaoundé, Cameroon
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA
| | - Milton L Wainberg
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, and New York State Psychiatric Institute, New York, NY, USA
| | - Brian W Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | | | - Marcel Yotebieng
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kathryn Anastos
- Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Denis Nsame
- Bamenda Regional Hospital, Bamenda, Cameroon
| | - Rogers Ajeh
- Clinical Research Education Networking and Consultancy, Yaoundé, Cameroon
| | | | - Angela M Parcesepe
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Shahid NN, Dale SK. Gendered Racial Microaggressions, Self-silencing, Substance Use, and HIV Outcomes Among Black Women Living with HIV: A Structural Equation Modeling Approach. AIDS Behav 2024; 28:1276-1290. [PMID: 37642823 DOI: 10.1007/s10461-023-04157-2] [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] [Accepted: 08/10/2023] [Indexed: 08/31/2023]
Abstract
To better understand factors that may contribute to HIV outcomes experienced by Black women living with HIV (BWLWH), the present study examined the relationships among gendered racial microaggressions (GRM; subtle daily insults due to racism and sexism), self-silencing, substance use, antiretroviral therapy (ART) medication adherence, and viral suppression using structural equation modeling and path analysis. Self-silencing and substance use were examined as potential mediators. Participants were 119 BWLWH residing in South Florida. Results of this study showed that GRM was directly and positively associated with self-silencing and indirectly and negatively associated with medication adherence via self-silencing. GRM was directly related to higher alcohol use disorder severity. Self-silencing was directly and negatively associated with medication adherence. Medication adherence was directly and negatively related to viral suppression. The model fit the data well. Identifying the negative consequences of GRM in conjunction with self-silencing and substance use may help inform prevention and intervention strategies to improve mental health and HIV-related outcomes among BWLWH.
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Affiliation(s)
- Naysha N Shahid
- Department of Psychology, University of Miami, Coral Gables, FL, USA
| | - Sannisha K Dale
- Department of Psychology, University of Miami, Coral Gables, FL, USA.
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Simms V, Abas MA, Müller M, Munetsi E, Dzapasi L, Weiss HA, Chibanda D. Effect of a brief psychological intervention for common mental disorders on HIV viral suppression: A non-randomised controlled study of the Friendship Bench in Zimbabwe. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0001492. [PMID: 38236786 PMCID: PMC10796049 DOI: 10.1371/journal.pgph.0001492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 09/19/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND For people living with co-morbid HIV and common mental disorders (CMD), it is not known whether a brief psychological intervention for CMD can improve HIV viral suppression. METHODS We conducted a prospective cohort study in eight primary care clinics in Harare, Zimbabwe, enrolling adults with co-morbid HIV and CMD. Six clinics provided the Friendship Bench (FB), a brief psychological intervention for CMD based on problem-solving therapy, delivered by lay counsellors. Two clinics provided enhanced usual care (EUC). The primary outcome was viral non-suppression after six months (viral load ≥400 copies/mL). Data were analysed using a difference-in-difference approach with linear regression of cluster-level proportions, adjusted for baseline viral non-suppression (aDiD). The secondary outcome was presence of CMD measured by the Shona Symptom Questionnaire. RESULTS In FB clinics, 407/500 (81.4%) participants had viral load results at baseline and endline: 58 (14.3%) had viral non-suppression at baseline and 41 (10.1%) at endline. In EUC clinics, 172/200 (86.0%) had viral load results at baseline and endline: 22 (12.8%) were non-suppressed at baseline and 26 (15.1%) at endline (aDiD = -7.3%; 95%CI 14.7% to -0.01%; p = 0.05). Of the 499 participants virally suppressed at baseline, the FB group had lower prevalence of non-suppression at endline compared to the EUC group (2.9% vs 9.3%; p = 0.002). There was no evidence of a difference in endline viral non-suppression by group among the 80 participants with non-suppression at baseline (53.5% vs 54.6%; p = 0.93). The FB group was less likely to screen positive for CMD at endline than the EUC group (aDiD = -21.6%; 95%CI -36.5% to -6.7%; p = 0.008). CONCLUSION People living with co-morbid HIV and CMD may benefit from receiving a low-cost mental health intervention to enhance viral suppression, especially if they are already virally suppressed. Research is needed to understand if additional adherence counselling could further improve viral suppression.
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Affiliation(s)
- Victoria Simms
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Melanie A. Abas
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Monika Müller
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
- University Hospital of Psychiatry Bern, Bern, Switzerland
| | | | | | - Helen A. Weiss
- MRC International Statistics and Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Dixon Chibanda
- Friendship Bench, Harare, Zimbabwe
- Department of Psychiatry, University of Zimbabwe, Harare, Zimbabwe
- Centre For Global Mental Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Alum EU, Obeagu EI, Ugwu OP, Samson AO, Adepoju AO, Amusa MO. Inclusion of nutritional counseling and mental health services in HIV/AIDS management: A paradigm shift. Medicine (Baltimore) 2023; 102:e35673. [PMID: 37832059 PMCID: PMC10578718 DOI: 10.1097/md.0000000000035673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Human immunodeficiency virus (HIV) infection is a public health challenge that can degenerate into acquired immunodeficiency syndrome (AIDS) if not properly managed. HIV infection shortens life expectancy to about 5 to 10 years compared to noninfected individuals. People living with HIV/AIDS (PLWHA) are prone to several health challenges as a result of a deranged immune system culminating in high morbidity and mortality. Depression is a common feature of PLWHA. Depression heightens the emergence of opportunistic infections in HIV-infected individuals, accelerates the progression to AIDS, and increased suicidal tendencies, morbidity, and mortality. Food insecurity with its resultant undernutrition contributes to HIV/AIDS-related deaths. Undernourished PLWHA are more prone to opportunistic infections due to poor immunity. Interestingly, proper diet intake can boost immunity, slow the progression of AIDS and opportunistic infections, enhance body weight, and retard depression tendencies. Undernutrition can also be ameliorated by incorporating nutritional counseling and oral nutrient supplementation in routine HIV/AIDS checkups. Therefore, to increase HIV/AIDS management outcomes, the integration of nutrition counseling, dietary supplements, and mental health services should be embraced. Thus, HIV/AIDS care centers should amplify these services. In this article, we isolated relevant studies from various databases, illuminated the interwoven relationship between HIV/AIDS, depression, and undernutrition, and also reemphasized the need for adequate nutritional intervention in the battle against HIV/AIDS. Thus, this study provides a reawakening call to focus on incorporating nutritional guides and mental health care in HIV/AIDS management protocols.
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Affiliation(s)
- Esther U. Alum
- Department of Publications and Extension, Kampala International University, Kampala, Uganda
- Department of Biochemistry, Faculty of Science, Ebonyi State University, Ebonyi State, Nigeria
| | | | - Okechukwu P.C. Ugwu
- Department of Publications and Extension, Kampala International University, Kampala, Uganda
| | | | | | - Mariam O. Amusa
- Department of Botany and Plant Biotechnology, University of Johannesburg, Johannesburg, South Africa
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Madundo K, Knettel BA, Knippler E, Mbwambo J. Prevalence, severity, and associated factors of depression in newly diagnosed people living with HIV in Kilimanjaro, Tanzania: a cross-sectional study. BMC Psychiatry 2023; 23:83. [PMID: 36726113 PMCID: PMC9890688 DOI: 10.1186/s12888-022-04496-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 12/23/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Depression is particularly common among people living with Human Immunodeficiency Virus (HIV), with some studies showing a prevalence of depression three times higher among people living with HIV as compared to the general public. The stress associated with being diagnosed with HIV can be quite impactful, including concerns about one's long-term health, stigma, and the burden of long-term treatment. Therefore, it is common for a new HIV diagnosis to contribute to the onset of depressive symptoms. The objective of this study was to determine the prevalence and severity of depression, and its associated factors in people diagnosed with HIV within the past 12 months. METHODS We conducted a cross-sectional survey with patients newly diagnosed with HIV at three hospitals in the Kilimanjaro region of Tanzania utilizing a locally validated version of the Patient Health Questionnaire-9 (PHQ-9) as a screener for depression, the Demographic Health Survey (SES-DHS8) for socio-demographic characteristics, and the Duke-UNC Functional Social Support Questionnaire (FSSQ) to assess perceived social support. We enrolled 272 participants between September and December 2020, diagnosed with HIV within the past 12 months. Analysis of Co-variance (ANCOVA) and Bonferroni post-hoc analysis were used to determine associations of sociodemographic variables with the dependent variable of depression. RESULTS Overall prevalence of depression in our sample was 41%, including 54 participants (20%) with moderate symptoms, 42 (15%) with moderately severe symptoms, and 16 (6%) with severe symptoms. Severity was highest in participants diagnosed with HIV less than 1 month ago. An ANCOVA model (overall F = 4.72, p < 0.001) assessing factors associated with greater depression severity revealed significant effects of study site (F = 7.6, p < 0.001), female gender (F = 5.11, p = 0.02), and less time since HIV diagnosis (F = 12.3, p < 0.001). CONCLUSION The study demonstrates very high prevalence of depression among people living with HIV in this setting, particularly among those newly diagnosed, female participants, and those seen at the larger regional referral hospital. Integration of mental health screening and interventions into CTC care is vital in the first visits following a positive test result and may be tailored to meet the needs of patients at highest risk for developing symptoms of depression.
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Affiliation(s)
- Kim Madundo
- Department of Mental Health and Psychiatry, Kilimanjaro Christian Medical Centre, Moshi, Tanzania.
| | - Brandon A Knettel
- Duke University School of Nursing and Duke Global Health Institute, Durham, NC, USA
| | - Elizabeth Knippler
- Duke Centre for AIDS Research, Duke University School of Nursing, Durham, NC, USA
| | - Jessie Mbwambo
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Kulisewa K, Minnick CE, Stockton MA, Gaynes BN, Hosseinipour MC, Mphonda S, Sansbury G, Udedi MM, Pence BW. The acceptability of antidepressant treatment in people living with HIV in Malawi: A patient perspective. Glob Public Health 2023; 18:2201327. [PMID: 37088107 PMCID: PMC10465971 DOI: 10.1080/17441692.2023.2201327] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 04/04/2023] [Indexed: 04/25/2023]
Abstract
Depression is common among people living with HIV (PLWH). Measurement-based care models that measure depression severity and antidepressant side effects, and use an algorithm to guide antidepressant prescription by non-specialized health workers represent an evidence-based treatment for severe depression in sub-Saharan Africa. We conducted in-depth interviews from June to December 2018 with eleven patients enrolled in Project SOAR-Mental Health, a pilot project integrating depression treatment into HIV care in Malawi. Patients treated with amitriptyline or fluoxetine participated in interviews exploring antidepressant acceptability through patient knowledge, side effect severity, pill burden, adherence, perceived efficacy, and tolerability. Patients described a lack of detailed antidepressant education from their providers. Variable, typically self-limiting side effects were reported from both amitriptyline and fluoxetine. While most side effects were mild, three patients reported functional impairment. Patients reported high adherence, though the additional pill burden was a challenge. Most patients found the antidepressants efficacious, tolerable, beneficial and acceptable. Although patient psychoeducation is notably lacking as a facet of clinical management, antidepressant prescription by primary care providers appears acceptable for comorbid severe depression in PLWH initiating HIV care in sub-Saharan Africa. Health workers should be mindful of dosing to minimise side effects and considerate of the additional pill burden.Trial registration: ClinicalTrials.gov ID [NCT03555669]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Caroline E. Minnick
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Mina C. Hosseinipour
- Tidziwe Centre, University of North Carolina Project-Malawi, Lilongwe, Malawi
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Steven Mphonda
- Tidziwe Centre, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | - Griffin Sansbury
- Tidziwe Centre, University of North Carolina Project-Malawi, Lilongwe, Malawi
| | | | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
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Ndenkeh JJN, Nji AM, Yumo HA, Rothe C, Kroidl A. Depression management and antiretroviral treatment outcome among people living with HIV in Northwest and East regions of Cameroon. BMC Infect Dis 2022; 22:732. [PMID: 36100890 PMCID: PMC9469586 DOI: 10.1186/s12879-022-07711-w] [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: 02/17/2022] [Accepted: 08/26/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Several interventions have shown benefits in improving mental health problems such as depression which is common in people living with HIV. However, there is a paucity of evidence on the effect of these interventions in improving HIV treatment outcomes. This study aimed at bridging this evidence gap and guiding the integration of depression and HIV management, particularly in rural health settings of Cameroon.
Materials and methods
We carried out a cluster-randomized intervention study targeting persons aged 13 years and above who had been on antiretroviral treatment for 6–9 months. Participants were followed up for 12 months during which those in the intervention group underwent routine screening and management of depression. Comparisons were done using the two-way ANOVA and Chi-squared test with significance set at 5%.
Results
Overall, 370 participants with a median age of 39 years (IQR: 30–49) were enrolled in this study. Of these, 42 (11.3%) were screened with moderate to severe depressive symptoms and 41 (11.1%) had poor treatment adherence. There was a significant drop in depression scores in the intervention group from 3.88 (± 3.76) to 2.29 (± 2.39) versus 4.35 (± 4.64) to 3.39 (± 3.0) in controls (p < 0.001) which was accompanied by a drop in the prevalence of moderate to severe depressive symptoms in the intervention group from 9% to 0.8% (p = 0.046). Decreased depression scores were correlated with better adherence scores with correlation coefficients of − 0.191, − 0.555, and − 0.513 at baseline, 6 months, and 12 months of follow-up respectively (p < 0.001) but there was no significant difference in adherence levels (p = 0.255) and viral suppression rates (p = 0.811) between groups.
Conclusion
The results of this study suggest that considering routine screening and management of depression as an integral component of HIV care could positively impact HIV treatment outcomes. However, there is a need for more research to identify the best combinations of context-specific and cost-effective strategies that can impactfully be integrated with HIV management.
Trial registration Trial registration Number: DRKS00027440. Name of Registry: German Clinical Trials Register. Date registration: December 10, 2021 (‘retrospectively registered’). Date of enrolment of the first participant: 05/08/2019
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Screening PLHIV for depression using PHQs: A RCT comparing non-selective with selective screening strategy within a primary health care facility in Uganda. PLoS One 2022; 17:e0270175. [PMID: 35767586 PMCID: PMC9242435 DOI: 10.1371/journal.pone.0270175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 06/01/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Depression is rarely screened for among People Living with Human Immunodeficiency Virus (PLHIV) although it is 2 to 3 times more prevalent among PLHIV than in the general population. In instances where depression is screened for using screening tools, it usually follows noticing depression risk factors. This practice of selectively screening for depression could be leaving some cases of depression unattended to. On the other hand, subjecting every client to screening tools (non-selective screening) offers every patient an opportunity to be managed for depression. However, this could require additional resources as compared to selective screening. We present and discuss results on whether non-selective and selective screening strategies differ in depression case detection, and in addition, we also present perceptions of the stake holders on the two screening strategies. METHODS The study was conducted in Princess Diana Memorial Health Centre IV HIV clinic using a randomized controlled trial with a qualitative component. To determine whether there was a difference in depression case detection, consecutively sampled participants were randomly allocated to either non-selective or selective screening strategy. Participants allocated to selective screening were screened for depression using the patient health questionnaire (s) (PHQs) if they were at "crisis points". While those allocated to non-selective screening were screened regardless of whether the "crisis points" were noticed or not. The PHQ-2 and PHQ-9 were used in sequence. 326 PLHIV participated in the study. Outcomes of the MINI evaluation were analyzed for those with PHQ-9 scores of 10 or more to confirm major depressive disorder (MDD). Data was analyzed using the two sample Z-test for proportions with Stata 2013 software. To explore the perceptions of the stake holders, key informant interviews were performed with six stakeholders that experienced the study. RESULTS Cases of depression (PHQ-9 score ≥ 5) were more likely to be detected by the non-selective screening strategy 30.2% (49/162) compared to the selective screening strategy 19.5% (32/164) (difference in proportions 0.107, 95% confidence interval 0.014-0.200, Cohen's h = 0.25, P = 0.03). The stake holders thought it was important to screen for depression among PLHIV with preference to non-selective screening strategy. CONCLUSION Evidence from this data suggests that more cases of depression (PHQ-9 score ≥ 5) are likely to be detected with non-selective screening as opposed to selective screening. TRIAL REGISTRATION PACTR201802003141213 (name: comparison of routine versus selective screening for depression strategies among PLHIV attending Princess Diana Memorial Health Centre iv Soroti).
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El-Halabi S, Cooper DH, Cha DS, Rosenblat JD, Gill B, Rodrigues NB, Lipsitz O, McIntyre RS, Gill H. The effects of antidepressant medications on antiretroviral treatment adherence in HIV-positive individuals with depression. J Affect Disord 2022; 300:219-225. [PMID: 34952118 DOI: 10.1016/j.jad.2021.12.083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 09/05/2021] [Accepted: 12/19/2021] [Indexed: 11/26/2022]
Abstract
Background Extant literature has identified Major Depressive Disorder (MDD) as a comorbid disorder in individuals with seropositive human immunodeficiency disorder (HIV), and this may affect HIV-treatment efficacy. However, there is a paucity of literature evaluating the effects of antidepressant use on antiretroviral therapies (ART) in HIV-positive individuals. Herein, the following review assesses the effects of antidepressant medications on ART adherence in HIV-positive individuals with diagnosed MDD. Methods A systematic search on PubMed, Scopus, Web of Science, and Google Scholar search engines were conducted between database inception to June 12th, 2020 using the search and MeSH terms: (HIV) AND (antiretroviral or treatment) AND (depress*) AND (antidepressants) AND (adherence). Results We identified nine articles that evaluated ART adherence in HIV-positive individuals using antidepressants. Of the nine included articles, eight articles evaluated participants undergoing ART, and one article evaluated participants undergoing highly active antiretroviral therapy (HAART). Our primary findings suggest that patients who took antidepressant treatment for depression demonstrated greater adherence to HIV treatments and a reduction in missed HIV medication dosage. Limitations The heterogeneity of study design between the included studies was high. Conclusion The current review suggests that response to antidepressant medication may improve adherence to HIV treatments in HIV-positive individuals with comorbid depression. Further studies should expand the findings to explore the effects of disparate psychotropic agents on adherence behaviors among patients with HIV to identify the benefits of these agents on long-term health outcomes in this vulnerable clinical population.
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Affiliation(s)
- Sabine El-Halabi
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Daniel H Cooper
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Danielle S Cha
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Joshua Daniel Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Barjot Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Nelson B Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Orly Lipsitz
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Pharmacology, University of Toronto, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Brain and Cognition Discovery Foundation, Toronto, ON, Canada
| | - Hartej Gill
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada.
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Stockton MA, Minnick CE, Kulisewa K, Mphonda SM, Hosseinipour MC, Gaynes BN, Maselko J, Pettifor AE, Go V, Udedi M, Pence BW. A Mixed-Methods Process Evaluation: Integrating Depression Treatment Into HIV Care in Malawi. GLOBAL HEALTH, SCIENCE AND PRACTICE 2021; 9:611-625. [PMID: 34593585 PMCID: PMC8514021 DOI: 10.9745/ghsp-d-20-00607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 06/08/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND Depression is highly prevalent among people living with HIV in Malawi. Depression can undermine engagement in HIV care and worsen HIV morbidity and mortality. The Ministry of Health integrated a pilot depression management program into HIV care at 2 clinics. This program included a measurement-based care protocol for prescribing antidepressants and an adapted Friendship Bench psychotherapy protocol for providing problem solving. Early evaluations indicated successful integration of the initial stages of training and depression screening, diagnosis, and treatment initiation. This follow-up mixed-method investigation contextualizes our previous findings and shares insights from the implementation experience. METHODS We conducted a mixed-methods process evaluation drawing on both patient clinical data and qualitative interviews with patients and clinic staff. We focus on the following implementation outcomes: fidelity, acceptability, and sustainability. RESULTS Although fidelity to depression screening and treatment initiation was high, fidelity to the follow-up treatment protocol was poor. Antidepressants and problem-solving therapy were acceptable to patients, but clinic staff found delivering treatment challenging given constrained human resources and infrastructure. The program was not sustained after the project. Key identified needs included substantial support to supervise the implementation of the program, continue to build and maintain the capacity of providers, integrate the program into the electronic medical records system, and ensure the availability of Friendship Bench counselors. CONCLUSIONS Although initial steps were successful, sustained integration of this depression treatment program into HIV care in this setting met greater challenges. Implementation science studies that support both implementation and evaluation should recognize the potential for clinical implementers to rely on evaluation staff for clinical support and consider distancing evaluation staff from the actual program implementation. Further research is needed to test enhanced implementation strategies for integrating evidence-based mental health interventions into existing health care systems in a sustainable fashion, particularly in low-resource settings.
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Affiliation(s)
- Melissa A Stockton
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Caroline E Minnick
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Steven M Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Mina C Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Bradley N Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Joanna Maselko
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Audrey E Pettifor
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Vivian Go
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael Udedi
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Noncommunicable Diseases and Mental Health Unit, Ministry of Health, Lilongwe, Malawi
| | - Brian W Pence
- Epidemiology Department, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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12
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McBain RK, Mwale O, Ruderman T, Kayira W, Connolly E, Chalamanda M, Kachimanga C, Khongo BD, Wilson J, Wroe E, Raviola G, Smith S, Coleman S, Kelly K, Houde A, Tebeka MG, Watson S, Kulisewa K, Udedi M, Wagner G. Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial. Trials 2021; 22:630. [PMID: 34530894 PMCID: PMC8444539 DOI: 10.1186/s13063-021-05601-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 09/04/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease-including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. The lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in antiretroviral therapy (ART). As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes. METHODS We will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9) and Mini-International Neuropsychiatric Interview (MINI). Roll-out will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g., HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every 3 months through 12-month follow-up. We will also evaluate the model's cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model. DISCUSSION This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. If determined to be cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence. TRIAL REGISTRATION ClinicalTrials.gov NCT04777006 . Registered on 1 March, 2021.
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Affiliation(s)
- Ryan K McBain
- RAND Corporation, Boston, 20 Park Plz, Boston, MA, 02116, USA.
- Partners In Health, Boston, MA, USA.
| | - Owen Mwale
- Partners in Health, Neno District, Malawi
| | | | | | - Emilia Connolly
- Partners in Health, Neno District, Malawi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Division of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | | | | | | | - Emily Wroe
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Giuseppe Raviola
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Stephanie Smith
- Partners In Health, Boston, MA, USA
- Brigham & Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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13
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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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14
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Solomon D, Tariq S, Alldis J, Burns F, Gilson R, Sabin C, Sherr L, Pettit F, Dhairyawan R. Ethnic inequalities in mental health and socioeconomic status among older women living with HIV: results from the PRIME Study. Sex Transm Infect 2021; 98:128-131. [PMID: 33782143 PMCID: PMC8862077 DOI: 10.1136/sextrans-2020-054788] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 02/12/2021] [Accepted: 02/20/2021] [Indexed: 02/03/2023] Open
Abstract
Objectives Women living with HIV in the UK are an ethnically diverse group with significant psychosocial challenges. Increasing numbers are reaching older age. We describe psychological and socioeconomic factors among women with HIV in England aged 45–60 and explore associations with ethnicity. Methods Analysis of cross-sectional data on 724 women recruited to the PRIME Study. Psychological symptoms were measured using the Patient Health Questionnaire 4 and social isolation with a modified Duke-UNC Functional Social Support Scale. Results Black African (BA) women were more likely than Black Caribbean or White British (WB) women to have a university education (48.3%, 27.0%, 25.7%, respectively, p<0.001), but were not more likely to be employed (68.4%, 61.4%, 65.2%, p=0.56) and were less likely to have enough money to meet their basic needs (56.4%, 63.0%, 82.9%, p<0.001). BA women were less likely to report being diagnosed with depression than WB women (adjusted odds ratio (aOR) 0.40, p<0.001) but more likely to report current psychological distress (aOR 3.34, p<0.05). Conclusions We report high levels of poverty, psychological distress and social isolation in this ethnically diverse group of midlife women with HIV, especially among those who were BA. Despite being more likely to experience psychological distress, BA women were less likely to have been diagnosed with depression suggesting a possible inequity in access to mental health services. Holistic HIV care requires awareness of the psychosocial needs of older women living with HIV, which may be more pronounced in racially minoritised communities, and prompt referral for support including psychology, peer support and advice about benefits.
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Affiliation(s)
- Danielle Solomon
- Institute for Global Health, University College London, London, UK
| | - Shema Tariq
- Institute for Global Health, University College London, London, UK
| | - Jon Alldis
- London South Bank University, London, UK
| | - Fiona Burns
- Institute for Global Health, University College London, London, UK.,Royal Free London NHS Foundation Trust, London, UK
| | - Richard Gilson
- Institute for Global Health, University College London, London, UK
| | - Caroline Sabin
- Institute for Global Health, University College London, London, UK
| | - Lorraine Sherr
- Institute for Global Health, University College London, London, UK
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15
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Manshadi Seyed Ali D, Seyed Alireza M, Mohammad Reza S, Jayran Z, SeyedAhmad S, Shams Ali R, Seyed Saeid M, Ali AA. Effect of green tea consumption in treatment of mild to moderate depression in Iranian patients living with HIV: A double-blind randomized clinical trial. CHINESE HERBAL MEDICINES 2021; 13:136-141. [PMID: 36117757 PMCID: PMC9476475 DOI: 10.1016/j.chmed.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/20/2020] [Accepted: 08/05/2020] [Indexed: 11/28/2022] Open
Affiliation(s)
- Dehghan Manshadi Seyed Ali
- Department of Infectious Diseases and Tropical Medicine, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Tehran 11519, Iran
| | - Mousavi Seyed Alireza
- Department of Infectious Diseases and Tropical Medicine, Shahid Sadoughi Hospital, Shahid Sadoughi University of Medical Sciences and Health Services, Yazd 11519, Iran
| | - Salehi Mohammad Reza
- Department of Infectious Diseases and Tropical Medicine, Imam-Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Tehran 11519, Iran
| | - Zebardast Jayran
- Cognitive Neuroscience Linguistics, Institute for Cognitive Science Studies (ICSS), Tehran 11519, Iran
| | - SeyedAlinaghi SeyedAhmad
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran 11519, Iran
| | - Rezazade Shams Ali
- Medicinal Plants Research Center, Institute of Medicinal Plants, ACECR, Tehran 11519, Iran
| | - Mirhoseinian Seyed Saeid
- Department of Pharmacognosy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran 11519, Iran
| | - Asadollahi-Amin Ali
- Iranian Research Center for HIV/AIDS, Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran 11519, Iran
- Corresponding author.
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16
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Ezeanolue EE, Iheanacho T, Adedeji IA, Itanyi IU, Olakunde B, Patel D, Dakum P, Okonkwo P, Akinmurele T, Obiefune M, Khamofu H, Oyeledun B, Aina M, Eyo A, Oleribe O, Oko J, Olutola A, Gobir I, Aliyu MH, Aliyu G, Woelk G, Aarons G, Siberry G, Sturke R. Opportunities and challenges to integrating mental health into HIV programs in a low- and middle-income country: insights from the Nigeria implementation science Alliance. BMC Health Serv Res 2020; 20:904. [PMID: 32993621 PMCID: PMC7526407 DOI: 10.1186/s12913-020-05750-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 09/21/2020] [Indexed: 11/10/2022] Open
Abstract
Background In Nigeria, there is an estimated 1.9 million people living with HIV (PLHIV), 53% of whom utilize HIV care and services. With decreasing HIV-related deaths and increasing new infections, HIV with its associated comorbidities continue to be a key public health challenge in Nigeria. Untreated, comorbid mental disorders are a critical but potentially modifiable determinant of optimal HIV treatment outcomes. This study aimed to identify the challenges and opportunities related to integrating mental health care into existing HIV programs in Nigeria. Method Attendees at the Nigeria Implementation Science Alliance (NISA)‘s 2019 conference participated in nominal group technique (NGT) exercise informed by the “Exploration, Preparation, Implementation, and Sustainment (EPIS)” framework. The NGT process was conducted among the nominal groups in two major sessions of 30-min phases followed by a 30-min plenary session. Data analysis proceeded in four steps: transcription, collation, theming and content analysis. Results The two major theoretical themes from the study were – opportunities and challenges of integrating mental health treatment into HIV services. Three sub-themes emerged on opportunities: building on health care facilities for HIV services (screening, counseling, task-sharing monitoring and evaluation frameworks), utilizing existing human resources or workforce in HIV programs (in-service training and including mental health in education curriculum) and the role of social and cultural structures (leveraging existing community, traditional and faith-based infrastructures). Four sub-themes emerged for challenges: double burden of stigma and the problems of early detection (HIV and mental health stigma, lack of awareness), existing policy gaps and structural challenges (fragmented health system), limited human resources for mental health care in Nigeria (knowledge gap and burnout) and dearth of data/evidence for planning and action (research gaps). Conclusions Potential for integrating treatments for mental disorders into HIV programs and services exist in Nigeria. These include opportunities for clinicians’ training and capacity building as well as community partnerships. Multiple barriers and challenges such as stigma, policy and research gaps would need to be addressed to leverage these opportunities. Our findings serve as a useful guide for government agencies, policy makers and research organizations to address co-morbid mental disorders among PLHIV in Nigeria.
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Affiliation(s)
- Echezona E Ezeanolue
- Center for Translation and Implementation Research, Institute of Maternal and Child health, University of Nigeria Nsukka, Enugu Campus, Enugu, Nigeria.,Healthy Sunrise Foundation, Las Vegas, NV, USA
| | - Theddeus Iheanacho
- Department of Psychiatry, Yale University School of Medicine, Yale University, 300 George Street, New Haven, CT, 06511, USA.
| | | | - Ijeoma Uchenna Itanyi
- Center for Translation and Implementation Research, Institute of Maternal and Child health, University of Nigeria Nsukka, Enugu Campus, Enugu, Nigeria.,Department of Community Medicine, University of Nigeria, Enugu, Nigeria
| | - Babayemi Olakunde
- Center for Translation and Implementation Research, Institute of Maternal and Child health, University of Nigeria Nsukka, Enugu Campus, Enugu, Nigeria.,National Agency for Control of AIDS, Abuja, Nigeria
| | - Dina Patel
- Healthy Sunrise Foundation, Las Vegas, NV, USA
| | - Patrick Dakum
- Institute of Human Virology, University of Maryland, Baltimore, MD, USA.,Institute of Human Virology, Abuja, Nigeria
| | | | | | | | | | | | | | - Andy Eyo
- Excellence Community Education Welfare Scheme, Abuja, Nigeria
| | - Obinna Oleribe
- Excellence and Friends Management Consult, Abuja, Nigeria
| | - John Oko
- Catholic Caritas Foundation Nigeria, Abuja, Nigeria
| | | | - Ibrahim Gobir
- Center for Global Health Practice and Impact, Georgetown University, Washington, USA
| | - Muktar H Aliyu
- Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gambo Aliyu
- National Agency for Control of AIDS, Abuja, Nigeria
| | - Godfrey Woelk
- Elizabeth Glaser Pediatric AIDS Foundation, Washington, USA
| | | | - George Siberry
- United States Agency for International Development, Washington, USA
| | - Rachel Sturke
- Fogarty International Center, National Institutes of Health, Bethesda, MD, USA
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17
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Xiao X, Chen C, Gao C, Wang H, Reynolds NR. Ways of coping mediate the relationship between self-efficacy for managing HIV and acceptance of illness among people living with HIV. J Adv Nurs 2020; 76:2945-2954. [PMID: 32893375 DOI: 10.1111/jan.14488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 06/02/2020] [Accepted: 07/06/2020] [Indexed: 12/01/2022]
Abstract
AIM The purpose of this study was to examine the relationship between self-efficacy for managing HIV and acceptance of illness and to identify the potential mediation effect of active coping and passive coping on this relationship. DESIGN The study used a cross-sectional survey. METHODS A sample of 555 people living with HIV were recruited from September-December 2018 in the HIV clinic of a tertiary general hospital in Changsha, China. Survey data were collected through face-to-face interviews that included measures of sociodemographic and HIV-related clinical characteristics, Acceptance of Illness Scale, the Simplified Coping Style Questionnaire and the Self-efficacy for Managing Chronic Disease Scale. Step-by-step linear regression models combined with bootstrap testing were used to test the relationships when controlling for gender and HIV diagnosis duration. RESULTS Self-efficacy was positively related to acceptance of illness and this relationship was partially mediated by both active coping and passive coping. Acceptance of illness increased by 0.175 for every point increase in self-efficacy indirectly through active coping, while acceptance of illness decreased by 0.034 for every point increase in self-efficacy via passive coping. CONCLUSION The findings highlighted the importance of self-efficacy for managing HIV and ways of coping, especially active coping, for illness acceptance. IMPACT The findings suggested that interventions that improve confidence in managing HIV and active coping may enhance the illness acceptance of people living with HIV.
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Affiliation(s)
- Xueling Xiao
- Xiangya School of Nursing of Central South University, Changsha, Hunan, China.,Johns Hopkins School of Nursing, Baltimore, MD, USA
| | - Chen Chen
- Xiangya School of Nursing of Central South University, Changsha, Hunan, China
| | - Chang Gao
- Xiangya School of Nursing of Central South University, Changsha, Hunan, China
| | - Honghong Wang
- Xiangya School of Nursing of Central South University, Changsha, Hunan, China
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18
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Hershow RB, Ha TV, Sripaipan T, Latkin C, Hutton HE, Chander G, Bui Q, Nguyen VQ, Frangakis C, Go VF. Perpetration of Intimate Partner Violence Among Men Living with HIV in Northern Vietnam. AIDS Behav 2020; 24:2555-2571. [PMID: 32078077 DOI: 10.1007/s10461-020-02813-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
We examined the prevalence of intimate partner violence (IPV) perpetration and characteristics of HIV-infected male perpetrators. The cross-sectional study was conducted in Vietnam with male antiretroviral treatment clients (N = 1099; mean age = 40.2 years). Bivariable associations were tested between psychological or physical/sexual IPV perpetration in the last 12 months and sociodemographic, psychosocial, and sexual behavioral factors using prevalence ratios. Factors significant at p < 0.10 were entered in multivariable models for each IPV outcome using a modified Poisson approach. Results showed 15.6% (N = 171/1099) reported perpetrating psychological IPV and 7.6% (N = 84/1099) perpetrating physical/sexual IPV in the last 12 months. HIV risk behaviors, including hazardous drinking and multiple sexual partners, having witnessed interparental violence as a child, and depressive symptoms were associated with perpetrating IPV. HIV interventions targeting HIV-infected men in Vietnam should intervene on IPV perpetration by addressing the co-occurring factors of sexual risk, depression, alcohol use, and child maltreatment that are correlated with IPV.
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Affiliation(s)
- Rebecca B Hershow
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA.
| | | | - Teerada Sripaipan
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Carl Latkin
- Department of Health, Behavior, and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Heidi E Hutton
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | - Constantine Frangakis
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Biostatistics, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Vivian F Go
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, Chapel Hill, NC, USA
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19
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Chinoda S, Mutsinze A, Simms V, Beji-Chauke R, Verhey R, Robinson J, Barker T, Mugurungi O, Apollo T, Munetsi E, Sithole D, Weiss HA, Chibanda D, Willis N. Effectiveness of a peer-led adolescent mental health intervention on HIV virological suppression and mental health in Zimbabwe: protocol of a cluster-randomised trial. Glob Ment Health (Camb) 2020; 7:e23. [PMID: 32963795 PMCID: PMC7490770 DOI: 10.1017/gmh.2020.14] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/01/2020] [Accepted: 07/05/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Adolescents living with HIV (ALHIV) experience a high burden of mental health disorder which is a barrier to antiretroviral therapy adherence. In Zimbabwe, trained, mentored peer supporters living with HIV (Community Adolescent Treatment Supporters - CATS) have been found to improve adherence, viral suppression and psychosocial well-being among ALHIV. The Friendship Bench is the largest integrated mental health programme in Africa. We hypothesise that combining the CATS programme and Friendship Bench will improve mental health and virological suppression among ALHIV compared with the CATS programme alone. METHODS We will conduct a cluster-randomised controlled trial in 60 clinics randomised 1:1 in five provinces. ALHIV attending the control arm clinics will receive standard CATS support and clinic support following the Ministry of Health guidelines. Those attending the intervention arm clinics will receive Friendship Bench problem-solving therapy, delivered by trained CATS. Participants with the signs of psychological distress will be referred to the clinic for further assessment and management. The primary outcome is HIV virological failure (≥1000 copies/ml) or death at 48 weeks. Secondary outcomes include the proportion of adolescents with common mental disorder symptoms (defined as Shona Symptom Questionnaire (SSQ-14) score ≥8), proportion with depression symptoms (defined as Patient Health Questionnaire (PHQ-9) score ≥11), symptom severity (mean SSQ-14 and PHQ-9 scores) and EQ-5D score for health-related quality of life. CONCLUSIONS This trial evaluates the effectiveness of peer-delivery of mental health care on mental health and HIV viral load among ALHIV. If effective this intervention has the potential to be scaled-up to improve these outcomes.Trial registration: PACTR201810756862405. 08 October 2018.
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Affiliation(s)
| | | | - Victoria Simms
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | - Taryn Barker
- Childrens’ Investment Fund Foundation, London, UK
| | - Owen Mugurungi
- AIDS & TB Unit, Ministry of Health and Child Care, Zimbabwe
| | - Tsitsi Apollo
- AIDS & TB Unit, Ministry of Health and Child Care, Zimbabwe
| | | | - Dorcas Sithole
- Ministry of Health and Child Care, Zimbabwe and Mental Health Services, Zimbabwe
| | - Helen A. Weiss
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Dixon Chibanda
- Friendship Bench, Harare, Zimbabwe
- Department of Psychiatry, University of Zimbabwe College of Health Sciences, Zimbabwe
- Centre for Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
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Seid S, Abdu O, Mitiku M, Tamirat KS. Prevalence of depression and associated factors among HIV/AIDS patients attending antiretroviral therapy clinic at Dessie referral hospital, South Wollo, Ethiopia. Int J Ment Health Syst 2020; 14:55. [PMID: 32742304 PMCID: PMC7391488 DOI: 10.1186/s13033-020-00389-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 07/23/2020] [Indexed: 11/10/2022] Open
Abstract
Introduction Depression is one of the common mental health disorders and predicted to be the second cause of the global health burden by the year 2020. Depression in HIV patients may lead to poor engagement to their HIV care which may finally result in poor treatment outcomes. Therefore, the aim of this study was to assess the prevalence of depression and associated factors among HIV/AIDS patients on ART at Dessie referral hospital. Methods An institution based cross-sectional study was conducted among 395 HIV positive adult patients on antiretroviral treatment from November to January 2019. The study participants were selected by using the systematic random sampling technique among patients who visited the antiretroviral (ART) clinic in the hospital and standardized Patients Health Questionnaire (PHQ-9) was used to measure depression. Descriptive statistics like percentage, median with interquartile range (IQR) was computed and presented in the form of text and table. Binary logistic regression model was fitted to identify factors associated with depression. An adjusted odds ratio (AOR) with a 95% confidence interval (CI) was used to identify factors associated with depression. Result The prevalence of depression was found to be 20% with (95% CI 16.2, 23.8). Age group of 25–34 years (AOR = 6.58, 95% CI 1.11, 38.9), widowed marital status (AOR = 7.05, 95% CI 2.32, 21.38), perceived stigma (AOR = 2.43, 95% CI 1.13, 5.21)], had opportunistic infections [AOR = 4.96, 95% CI (1.05, 23.34)], HIV non-disclosed HIV status (AOR = 6.34, 95% CI 1.34–29.65), poor and fair drug adherence (AOR = 7.1, 95% CI 2.06, 24.44), CD4 count ≤ 200 (AOR = 5.38, 95% CI 2.37–12.23) were factors significantly associated with depression. Conclusion The magnitude of depression was relatively lower than the pooled estimates for Ethiopia. Perceived stigma, younger age, widowed, being symptomatic, fair and poor adherence, recent opportunistic infection, low CD4 count, and HIV status not disclosed were positively associated with depression. This finding suggests the integration of mental health care with antiretroviral therapy and the special emphasis ought to be given for those at higher risk of depression.
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Affiliation(s)
- Seada Seid
- Amhara Regional Health Bureau, Borumeda Hospital, Dessie, Ethiopia
| | - Oumer Abdu
- Department of Internal Medicine, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Mebratu Mitiku
- Department of Internal Medicine, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
| | - Koku Sisay Tamirat
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
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Stockton MA, Udedi M, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Maselko J, Pettifor AE, Verhey R, Chibanda D, Lapidos-Salaiz I, Pence BW. The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi. PLoS One 2020; 15:e0231872. [PMID: 32374724 PMCID: PMC7202614 DOI: 10.1371/journal.pone.0231872] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 04/01/2020] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical. METHODS A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group. RESULTS Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)]. CONCLUSIONS While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.
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Affiliation(s)
- Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, Lilongwe, Malawi
- Department of Mental Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Kazione Kulisewa
- Department of Mental Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, United States of America
| | - Steven M. Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Lilongwe, Malawi
| | - Joanna Maselko
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Audrey E. Pettifor
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
| | - Ruth Verhey
- Friendship Bench Zimbabwe, Milton Park, Harare, Zimbabwe
| | - Dixon Chibanda
- Friendship Bench Zimbabwe, Milton Park, Harare, Zimbabwe
| | - Ilana Lapidos-Salaiz
- United States Agency for International Development (USAID), Arlington, VA, United States of America
| | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, United States of America
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Abelson A, Lyons C, Decker M, Ketende S, Mfochive Njindam I, Fouda G, Ndonko F, Levitt D, Tamoufe U, Billong S, Bissek ACZK, Baral SD. Lifetime experiences of gender-based violence, depression and condom use among female sex workers in Cameroon. Int J Soc Psychiatry 2019; 65:445-457. [PMID: 31234685 DOI: 10.1177/0020764019858646] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND In general populations, consistent data highlight the relationships among violence, HIV risk behavior and depression; however, these patterns are not well understood among female sex workers (FSWs). We examined the relationship between FSWs' experiences with sexual violence and consistent condom use as a key HIV risk behavior and explored mental health as a potential mediator. METHODS In total, 2,165 FSWs were recruited via respondent-driven sampling in Cameroon in 2016. The women answered questions about violence, condom use and mental health. RESULTS Inconsistent condom use with clients was reported by 23.5% of participants (508/2,165). Lifetime sexual violence was prevalent with 33.0% (713/2,163) of participants. Almost 50% (1,067/2,143) of respondents had some level of depression. Sexual violence was significantly associated with inconsistent condom use (adjusted risk ratio (aRR) 1.4, 95% confidence interval (CI) (1.2-1.6)). Of FSWs with no depression, 24.9% (267/1,071) reported sexual violence, versus 56.1% (32/57) of respondents with severe depression (p < .01). Severe depression significantly increased risk of condomless sex (aRR 1.8, 95% CI (1.3-2.6)); in mediation analysis, both sexual violence and severe depression remained significant predictors of condomless sex (aRR 1.4, 95% CI (1.2, 1.6) and aRR 1.7, 95% CI (1.2-2.4), respectively). Depression did not mediate the relationship between sexual violence and condom use. CONCLUSION Sexual violence and depression are prevalent and independently associated with condom nonuse with clients among FSWs in Cameroon. Results highlight the need for interventions to address mental health as well as gender-based violence for FSWs.
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Affiliation(s)
- Anna Abelson
- 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Carrie Lyons
- 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Michele Decker
- 2 Department of Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sosthenes Ketende
- 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | | | | | | | | | - Serge Billong
- 6 Groupe Technique Central du Comité National de Lutte contre le SIDA, Yaoundc, Cameroon
| | | | - Stefan D Baral
- 1 Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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The Role of Depression Screening and Treatment in Achieving the UNAIDS 90-90-90 Goals in Sub-Saharan Africa. AIDS Behav 2019; 23:153-161. [PMID: 31317365 PMCID: PMC6773678 DOI: 10.1007/s10461-019-02593-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Despite widespread HIV screening and treatment programs across sub-Saharan Africa, many countries are not on course to meet the Joint United Nations Program on HIV/AIDS 90–90–90 targets. As mental health disorders such as depression are prevalent among people living with HIV, investment in understanding and addressing comorbid depression is increasing. This manuscript aims to assess depression and HIV management in sub-Saharan Africa using a 90–90–90 lens through a discussion of: depression and the HIV care continuum; the state of depression screening and treatment; and innovations such as task-shifting strategies for depression management. Due to the lack of mental health infrastructure and human resources, task-shifting approaches that integrate mental health management into existing primary and community health programs are increasingly being piloted and adopted across the region. Greater integration of such mental health care task-shifting into HIV programs will be critical to realizing the 90–90–90 goals and ending the HIV epidemic.
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Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Pence BW. The effectiveness of depression management for improving HIV care outcomes in Malawi: protocol for a quasi-experimental study. BMC Public Health 2019; 19:827. [PMID: 31242877 PMCID: PMC6595692 DOI: 10.1186/s12889-019-7132-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 06/09/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Depression, prevalent among people living with HIV (PLWH) in Malawi, is associated with negative HIV patient outcomes and likely affects HIV medical management. Despite the high prevalence of depression, its management has not been integrated into HIV care in Malawi or most low-income countries. METHODS This study employs a pre-post design in two HIV clinics in Lilongwe, Malawi, to evaluate the effect of integrating depression management into routine HIV care on both mental health and HIV outcomes. Using a multiple baseline design, this study is examining mental health and HIV outcome data of adult (≥18 years) patients newly initiating ART who also have depression, comparing those entering care before and after the integration of depression screening and treatment into HIV care. The study is also collecting cost information to estimate the cost-effectiveness of the program in improving rates of depression remission and HIV treatment engagement and success. DISCUSSION We anticipate that the study will generate evidence on the effect of depression management on HIV outcomes and the feasibility of integrating depression management into existing HIV care clinics. The results of the study will inform practice and policy decisions on integration of depression management in HIV care clinics in Malawi and related settings, and will help design a next-step strategy to scale-up integration to a larger scale. TRIAL REGISTRATION ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Michael Udedi
- NCDs and Mental Health Unit, Ministry of Health, P. O. Box 30377, Capital City, Lilongwe 3, Malawi
- Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Melissa A. Stockton
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
| | - Kazione Kulisewa
- Department of Mental Health, University of Malawi, College of Medicine, P/Bag 360, Chichiri, Blantyre 3, Malawi
| | - Mina C. Hosseinipour
- Tidziwe Centre, University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Steven M. Mphonda
- Tidziwe Centre, University of North Carolina Project-Malawi, Private Bag A-104, Lilongwe, Malawi
| | - Brian W. Pence
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
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25
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Parcesepe AM, Mugglin C, Nalugoda F, Bernard C, Yunihastuti E, Althoff K, Jaquet A, Haas AD, Duda SN, Wester CW, Nash D. Screening and management of mental health and substance use disorders in HIV treatment settings in low- and middle-income countries within the global IeDEA consortium. J Int AIDS Soc 2019; 21:e25101. [PMID: 29603887 PMCID: PMC5878412 DOI: 10.1002/jia2.25101] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 03/08/2018] [Indexed: 11/28/2022] Open
Abstract
Introduction Integration of services to screen and manage mental health and substance use disorders (MSDs) into HIV care settings has been identified as a promising strategy to improve mental health and HIV treatment outcomes among people living with HIV/AIDS (PLWHA) in low‐ and middle‐income countries (LMICs). Data on the extent to which HIV treatment sites in LMICs screen and manage MSDs are limited. The objective of this study was to assess practices for screening and treatment of MSDs at HIV clinics in LMICs participating in the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Methods We surveyed a stratified random sample of 95 HIV clinics in 29 LMICs in the Caribbean, Central and South America, Asia‐Pacific and sub‐Saharan Africa. The survey captured information onsite characteristics and screening and treatment practices for depression, post‐traumatic stress disorder (PTSD), substance use disorders (SUDs) and other mental health disorders. Results Most sites (n = 76, 80%) were in urban areas. Mental health screening varied by disorder: 57% of sites surveyed screened for depression, 19% for PTSD, 55% for SUDs and 29% for other mental health disorders. Depression, PTSD, SUDs and other mental health disorders were reported as managed on site (having services provided at the HIV clinic or same health facility) at 70%, 51%, 41% and 47% of sites respectively. Combined availability of screening and on‐site management of depression, PTSD, and SUDs, and other mental health disorders was reported by 42%, 14%, 26% and 19% of sites, respectively. On‐site management of depression and PTSD was reported significantly less often in rural as compared to urban settings (depression: 33% and 78% respectively; PTSD: 24% and 58% respectively). Screening for depression and SUDs was least commonly reported by HIV programmes that treated only children as compared to HIV programmes that treated only adults or treated both adults and children. Conclusions Significant gaps exist in the management of MSDs in HIV care settings in LMICs, particularly in rural settings. Identification and evaluation of optimal implementation strategies to scale and sustain integrated MSDs and HIV care is needed.
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Affiliation(s)
- Angela M Parcesepe
- University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, NC, USA.,Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA
| | - Catrina Mugglin
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | | | - Charlotte Bernard
- Bordeaux Population Health Research Center, University of Bordeaux, INSERM, Bordeaux, France.,INSERM, ISPED, Bordeaux Population Health Research Center, Bordeaux, France
| | - Evy Yunihastuti
- Faculty of Medicine, Universitas Indonesia/Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Keri Althoff
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Antoine Jaquet
- Bordeaux Population Health Research Center, University of Bordeaux, INSERM, Bordeaux, France
| | - Andreas D Haas
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Stephany N Duda
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - C William Wester
- Department of Medicine, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN, USA.,Vanderbilt Institute for Global Health (VIGH), Nashville, TN, USA
| | - Denis Nash
- Institute for Implementation Science in Population Health, City University of New York, New York, NY, USA
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Digital depression screening in HIV primary care in South Africa: mood in retroviral + application monitoring [MIR + IAM]. Glob Ment Health (Camb) 2019; 6:e2. [PMID: 30854218 PMCID: PMC6401371 DOI: 10.1017/gmh.2018.35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/26/2018] [Accepted: 11/22/2018] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Integrating mental health care into HIV services is critical to addressing the high unmet treatment needs for people living with HIV and comorbid major depressive disorder. Introducing routine mental health screening at the primary health care level is a much needed diagonal approach to enhancing HIV care. In low-resource settings with a shortage of mental health care providers, eMental Health may provide a novel opportunity to attenuate this treatment gap and strengthen the health system. OBJECTIVE To conduct formative health systems research on the implementation of routine depression screening using a digital tool - Mood in Retroviral Positive Individuals Application Monitoring (MIR + IAM) - in an HIV primary care setting in South Africa. METHODS A Theory of Change (ToC) approach was utilised through individual and group session interviews to design an intervention that is embedded in the local context. Ten experts and local stakeholders were selected from the UK and South Africa. Data were analysed thematically using Atlas.ti to identify interventions, assumptions, barriers and facilitators of implementation. FINDINGS The participants considered digital depression screening in HIV care services relevant for the improvement of mental health in this population. The six main themes identified from the ToC process were: (1) user experience including acceptability by patients, issues of patient privacy and digital literacy, and the need for a patient-centred tool; (2) benefits of the digital tool for data collection and health promotion; (3) availability of treatment after diagnosis; (4) human and physical resource capacity of primary health care; (5) training for lay health care workers; and (6) demonstration of the intervention's usefulness to generate interest from decision-makers. CONCLUSION Digital depression screening coupled with routine mental health data collection and analysis in HIV care is an applicable service that could improve the mental and physical health outcomes of this population. Careful consideration of the local health system capacity, including both workers and patients, is required. Future research to refine this intervention should focus on service users, government stakeholders and funders.
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Parcesepe AM, Bernard C, Agler R, Ross J, Yotebieng M, Bass J, Kwobah E, Adedimeji A, Goulet J, Althoff KN. Mental health and HIV: research priorities related to the implementation and scale up of 'treat all' in sub-Saharan Africa. J Virus Erad 2018; 4:16-25. [PMID: 30515310 PMCID: PMC6248852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
World Health Organization (WHO) guidelines call for antiretroviral therapy (ART) for all people living with HIV (PLWH) regardless of CD4 cell count, a policy often referred to as 'treat all'. This article seeks to: (1) provide an overview of mental health research among PLWH in sub-Saharan Africa (SSA) and interventions or strategies to address comorbid mental illness among those living with HIV; and (2) describe key mental health-related recommendations to inform the successful implementation and scale up of 'treat all' policies in SSA. An initial set of mental health-related research recommendations was developed by a working group comprising investigators affiliated with the International epidemiology Databases to Evaluate AIDS (IeDEA) consortium. Recommendations were shared with those who attended the All-Africa IeDEA Meeting in Kigali, Rwanda in November 2017 and refined following the meeting. Recommendations reflect a need for epidemiological research to examine the prevalence, incidence, and impact of mental health multimorbidities on HIV treatment outcomes, intervention research to examine the extent to which improving the mental health of people living with HIV enhances HIV treatment outcomes, and implementation science research to evaluate promising models of integrated mental health and HIV care. Key research recommendations can advance understanding and treatment of mental illness among those living with HIV in sub-Saharan Africa and beyond.
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Affiliation(s)
- Angela M Parcesepe
- Corresponding author: Angela M. Parcesepe;
University of North Carolina at Chapel Hill,
Gillings School of Global Public Health,
Department of Maternal and Child Health,
CB#7445Chapel Hill,
NC,
27599-7445,
USA
| | | | - Robert Agler
- Department of Psychology, Ohio State University,
Columbus, OH,
USA
| | - Jeremy Ross
- TREAT Asia, amfAR - The Foundation for AIDS Research,
Bangkok,
Thailand
| | - Marcel Yotebieng
- College of Public Health, Division of Epidemiology, Ohio State University,
Columbus, OH,
USA
| | - Judith Bass
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD,
USA
| | - Edith Kwobah
- Department of Mental Health, Moi Teaching and Referral Hospital and Moi University,
Eldoret,
Kenya
| | - Adebola Adedimeji
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine,
Bronx, NY,
USA
| | | | - Keri N Althoff
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health,
Baltimore, MD,
USA
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Parcesepe AM, Bernard C, Agler R, Ross J, Yotebieng M, Bass J, Kwobah E, Adedimeji A, Goulet J, Althoff KN. Mental health and HIV: research priorities related to the implementation and scale up of ‘treat all’ in sub-Saharan Africa. J Virus Erad 2018. [DOI: 10.1016/s2055-6640(20)30341-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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29
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Ofori-Atta A, Reynolds NR, Antwi S, Renner L, Nichols JS, Lartey M, Amissah K, Tettey JK, Alhassan A, Ofori IP, Catlin AC, Gan G, Kyriakides TC, Paintsil E. Prevalence and correlates of depression among caregivers of children living with HIV in Ghana: findings from the Sankofa pediatric disclosure study. AIDS Care 2018; 31:283-292. [PMID: 30360643 DOI: 10.1080/09540121.2018.1537463] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Prior studies show an association between caregiver depression and child health outcomes. There has been little examination of depression among caregivers of HIV-infected children in sub-Saharan countries where pediatric HIV is concentrated. Using baseline data collected in the pediatric HIV disclosure intervention trial, Sankofa, we examined the prevalence and factors associated with depression among caregivers (N = 446) of children infected with HIV in Ghana. Data were analyzed with descriptive and regression analyses. The mean age of the caregivers was 42.2 ± 10.4 years. Eighty percent of the caregivers were female and 59% were HIV-infected. Twenty-eight percent (n = 126) of the caregivers were found to have mild to severe depression. In the adjusted model, factors significantly associated with caregiver depression included: HIV-positive caregiver status (P = 0.04), low income (P = 0.02), lower social support, (P = 0.01), lower HIV knowledge, (P = 0.01), worse HIV illness perceptions (P≤0.001), and greater perceived HIV stigma (P≤0.001). Although we found a high prevalence of depression among our study participants, several of the risks factors identified are modifiable and amenable to interventions that are locally available and affordable.
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Affiliation(s)
- Angela Ofori-Atta
- a Department of Psychiatry , University of Ghana School of Medicine and Dentistry and Korle-Bu Teaching Hospital Accra , Accra , Ghana
| | - Nancy R Reynolds
- b School of Nursing , Johns Hopkins University , Baltimore , MD , USA
| | - Sampson Antwi
- c Department of Child Health, School of Medical Sciences , Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital , Kumasi , Ghana
| | - Lorna Renner
- d Department of Child Health , University of Ghana School of Medicine and Dentistry and Korle-Bu Teaching Hospital Accra , Ghana
| | - Justin S Nichols
- e Department of Pediatrics , Yale School of Medicine , New Haven , CT , USA
| | - Margaret Lartey
- f Department of Medicine , University of Ghana School of Medicine and Dentistry and Korle-Bu Teaching Hospital Accra , Accra , Ghana
| | - Kofi Amissah
- c Department of Child Health, School of Medical Sciences , Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital , Kumasi , Ghana
| | - Jonas Kusah Tettey
- d Department of Child Health , University of Ghana School of Medicine and Dentistry and Korle-Bu Teaching Hospital Accra , Ghana
| | - Amina Alhassan
- c Department of Child Health, School of Medical Sciences , Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital , Kumasi , Ghana
| | - Irene Pokuaa Ofori
- c Department of Child Health, School of Medical Sciences , Kwame Nkrumah University of Science and Technology and Komfo Anokye Teaching Hospital , Kumasi , Ghana
| | - Ann C Catlin
- g Rosen Center for Advanced Computing , Purdue University , West Lafayette , IN , USA
| | - Geliang Gan
- h Yale Center for Analytical Sciences , Yale School of Public Health , New Haven , CT , USA
| | - Tassos C Kyriakides
- h Yale Center for Analytical Sciences , Yale School of Public Health , New Haven , CT , USA
| | - Elijah Paintsil
- e Department of Pediatrics , Yale School of Medicine , New Haven , CT , USA.,i Department of Pharmacology , Yale School of Medicine , New Haven , CT , USA.,j Department of Epidemiology & Public Health , Yale School of Medicine , New Haven , CT , USA
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30
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Passchier RV, Abas MA, Ebuenyi ID, Pariante CM. Effectiveness of depression interventions for people living with HIV in Sub-Saharan Africa: A systematic review & meta-analysis of psychological & immunological outcomes. Brain Behav Immun 2018; 73:261-273. [PMID: 29768184 DOI: 10.1016/j.bbi.2018.05.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 05/09/2018] [Accepted: 05/10/2018] [Indexed: 12/20/2022] Open
Abstract
This meta-analytic review evaluated the effectiveness of depression interventions on the psychological and immunological outcomes of people living with HIV in sub-Saharan Africa. 14 studies, yielding 932 participants were eligible. A random-effects models indicated that depression interventions were followed by large reductions in depression scores (effect size = 1.86, 95% CI = 1.71, 2.01, p < 0.01). No significant effect on immune outcome was observed, however there was a trend toward immune improvement of medium effect size (effect size on CD4 count and/or viral suppression = 0.57, 95% CI = -0.06, 1.20, p = 0.08). Pharmacological interventions appeared to have a significantly larger improvement in depression scores than psychological interventions. The greatest improvement in immune status was demonstrated in psychological treatments which incorporated a component to enhance HIV medication adherence, however these results did not reach significance. Small sample sizes and highly heterogeneous analysis necessitate caution in interpretation. The results of this meta-analysis should thus be treated as preliminary evidence and used to encourage further studies of immunopsychiatry in HIV in sub-Saharan Africa.
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Affiliation(s)
- Ruth Verity Passchier
- University of Cape Town, Department of Psychiatry and Mental Health, Anzio Road, Observatory, Cape Town, South Africa.
| | - Melanie Amna Abas
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, 16 De Crespigny Park, Camberwell, London SE5 8AF, United Kingdom
| | - Ikenna D Ebuenyi
- Vrije Universiteit Amsterdam, Athena Institute for Research on Innovation and Communication in Health and Life Sciences, Netherlands
| | - Carmine M Pariante
- Stress, Psychiatry and Immunology Laboratory, Institute of Psychiatry, Psychology & Neuroscience, King's College London, Maurice Wohl Clinical Neuroscience Institute, Cutcombe Road, London SE5 9RT, United Kingdom
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Hill LM, Kajula LJ, Maman S. Correlates of Anxiety and Depression among Young Men Living in Dar es Salaam, Tanzania. Int J Ment Health Addict 2018; 18:917-931. [PMID: 32863800 PMCID: PMC7450723 DOI: 10.1007/s11469-018-9993-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Depression and anxiety are important sources of morbidity globally, but we have little knowledge of risk groups and risk factors for both classes of disorders in Tanzania and other low-resource settings. We aimed to identify socio-demographic markers and risk and protective factors associated with symptoms of anxiety and depression among 1249 young men belonging to social groups known as "camps" in Dar es Salaam. Anxiety and depression were measured using the HSCL-25. Men living apart from family reported greater symptoms of anxiety and depression than men living with family, and employment was associated with a greater likelihood of clinically significant symptoms of both anxiety and depression. Childhood experience of violence was strongly associated with both anxiety and depression. Social support was associated with lower levels of anxiety and depression, and with a lower likelihood of clinically significant levels of anxiety and depression in this population. Youth not living with family and the working poor may be important populations for future investigation. Interventions targeting survivors of childhood violence and social support-based interventions should be tested to address the burden of anxiety and depression in this setting.
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Affiliation(s)
- Lauren M Hill
- Department of Health Behavior, UNC Chapel Hill, Chapel Hill, NC
| | - Lusajo J Kajula
- Department of Psychiatry and Mental Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Suzanne Maman
- Department of Health Behavior, UNC Chapel Hill, Chapel Hill, NC
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Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, Mwagomba BM, Mazenga AC, Pence BW. Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program. BMC Health Serv Res 2018; 18:593. [PMID: 30064418 PMCID: PMC6069990 DOI: 10.1186/s12913-018-3388-z] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/12/2018] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation. METHODS We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned. RESULTS We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care. CONCLUSIONS This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting. TRIAL REGISTRATION ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.
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Affiliation(s)
- Michael Udedi
- NCDs & Mental Health Unit, Ministry of Health, Ministry of Health, P. O. Box 30377 Capital City, Lilongwe 3, Malawi
| | - Melissa A. Stockton
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
| | - Kazione Kulisewa
- Ministry of Health, Kamuzu Central Hospital and Bwaila Psychiatric Hospital, Private Bag, 149 Lilongwe, Malawi
| | - Mina C. Hosseinipour
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag, A-104 Lilongwe, Malawi
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Bradley N. Gaynes
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516 USA
| | - Steven M. Mphonda
- University of North Carolina Project-Malawi, Tidziwe Centre, Private Bag, A-104 Lilongwe, Malawi
| | | | - Alick C. Mazenga
- Baylor College of Medicine Abbott Fund Children’s Clinical Centre of Excellence, Kamuzu Central Hospital, Private Bag, B-397 Lilongwe, Malawi
| | - Brian W. Pence
- Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599 USA
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Chan BT, Pradeep A, Mayer KH, Kumarasamy N. Attitudes of Indian HIV Clinicians Toward Depression in People Living with HIV. Ann Glob Health 2018; 82:792-797. [PMID: 28283131 DOI: 10.1016/j.aogh.2016.04.672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Depression is highly prevalent in people living with HIV (PLHIV) and is associated with increased morbidity and mortality. In India, where access to mental health specialists is limited, little is known about the attitude of HIV clinicians toward depression in PLHIV. METHODS We administered a questionnaire to HIV clinicians attending the 2015 Chennai Antiretroviral Therapy Symposium that assessed respondents' level of agreement with 29 statements regarding the etiology, importance, and management of depression and whether they felt capable and willing to manage depression in PLHIV. RESULTS The 69 respondents were from 9 Indian states. Most respondents agreed that depression in PLHIV is a serious problem (91%) and is associated with poorer HIV-related outcomes (62%-81%). Although most respondents (76%) reported feeling comfortable discussing mental health problems with PLHIV, almost half (48%) admitted that lack of knowledge and training about mental health issues hindered the diagnosis and treatment of depression in PLHIV. With few exceptions, there were no significant differences in responses by gender, urban/rural practice location, or government versus private practice. CONCLUSIONS Indian HIV clinicians believe that depression in PLHIV is important and are willing to manage depression in the HIV primary care setting. These findings suggest that HIV clinicians require further training to deliver evidence-based interventions to treat PLHIV with depression.
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Affiliation(s)
- Brian T Chan
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Amrose Pradeep
- Y.R. Gaitonde Centre for AIDS Research and Education, Chennai, India
| | - Kenneth H Mayer
- Harvard Medical School, Boston, MA; Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Boston, MA; Fenway Health, Boston, MA
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Changes in Anxiety and Depression Symptoms Predict Sexual Risk Behaviors Among Young Men Living in Dar es Salaam, Tanzania. AIDS Behav 2018; 22:1435-1445. [PMID: 29168066 DOI: 10.1007/s10461-017-1991-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Young men are important targets in HIV prevention in Tanzania and throughout sub-Saharan Africa. Anxiety and depression are common among youth and may be important predictors of HIV risk behaviors; evidence of these relationships in high-risk populations is needed. Using baseline and 1 year follow-up assessments from an HIV prevention trial we assessed the association between changes in symptoms of anxiety and depression and follow-up sexual risk behaviors (condom use and sexual partner concurrency) controlling for baseline sexual risk behaviors among 1113 male members of social groups known as "camps" in Dar es Salaam, Tanzania. Anxiety and depression were measured using the HSCL-25 and condom use and sexual partner concurrency were assessed through self-report. In separate models, increases in anxiety and depression were associated with sexual partner concurrency and with lower levels of condom use. In a combined model, both anxiety and depression appeared to independently affect concurrency but only depression was independently associated with condom use, with the association between anxiety and condom use being likely attributable to covariance with depression symptoms. The results of this study indicate the importance of screening and providing treatment for depression and anxiety disorders in high HIV-prevalence contexts, and the need to develop effective HIV prevention interventions targeting young men living with anxiety and depression.
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Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial. Trials 2018; 19:193. [PMID: 29566739 PMCID: PMC5863840 DOI: 10.1186/s13063-018-2517-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/02/2018] [Indexed: 01/15/2023] Open
Abstract
Background The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART. Methods The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively. Discussion The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings. Trial registration ClinicalTrials.gov (NCT02407691) registered on 19 March 2015; Pan African Clinical Trials Registry (201504001078347) registered on 19/03/2015; South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048) NHREC number 4048 issued on 21/04/2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2517-7) contains supplementary material, which is available to authorized users.
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Lofgren SM, Nakasujja N, Boulware DR. Systematic Review of Interventions for Depression for People Living with HIV in Africa. AIDS Behav 2018; 22:1-8. [PMID: 28900756 DOI: 10.1007/s10461-017-1906-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Depression interventions for individuals with HIV/AIDS in Africa are being increasingly evaluated. MEDLINE was searched using key terms: depression, Africa, and HIV, to identify depression interventions for HIV-infected adults in Africa. Perinatal women were excluded. Results were extracted and relative change in depression scores for interventions and net effect calculated. The MEDLINE search yielded 18 articles. Six of seven studies evaluating feasibility were positive, and seven of seven studies evaluating acceptability were also positive. Three studies investigated the effect of psychotherapy (% relative decrease of depressive symptoms for intervention: %net decrease compared to controls) (73%:39% decrease). Four studies investigated task-shifting of psychotherapy (47%:34% decrease). Three studies evaluated antidepressants (79%:39% decrease). Three studies investigated task-shifting of antidepressant treatment (82%:65% decrease). An exercise intervention was evaluated (66%:49% decrease). One trial investigated minocycline with non-statistically significant results. Finally, three studies investigated other psychosocial interventions (44%:21% decrease). Overall, the results highlight the need for large, randomized trials to establish efficacy as well as implementation studies.
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Mills JC, Harman JS, Cook RL, Marlow NM, Harle CA, Duncan RP, Gaynes BN, Pence BW. Comparative effectiveness of dual vs. single-action antidepressants on HIV clinical outcomes in HIV-infected people with depression. AIDS 2017; 31:2515-2524. [PMID: 28832409 PMCID: PMC5680130 DOI: 10.1097/qad.0000000000001618] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Depression is highly prevalent among people living with HIV/AIDS (PLWHA) and has deleterious effects on HIV clinical outcomes. We examined changes in depression symptoms, viral suppression, and CD4 T cells/μl among PLWHA diagnosed with depression who initiated antidepressant treatment during routine care, and compared the effectiveness of dual-action and single-action antidepressants for improving those outcomes. DESIGN Comparative effectiveness study of new user dual-action or single-action antidepressant treatment episodes occurring from 2004 to 2014 obtained from the Center for AIDS Research Network of Integrated Clinical Systems. METHODS We identified new user treatment episodes with no antidepressant use in the preceding 90 days. We completed intent-to-treat and per protocol evaluations for the main analysis. Primary outcomes, were viral suppression (HIV viral load <200 copies/ml) and CD4 T cells/μl. In a secondary analysis, we used the Patient Health Questionnaire-9 (PHQ-9) to evaluate changes in depression symptoms and remission (PHQ <5). Generalized estimating equations with inverse probability of treatment weights were fitted to estimate treatment effects. RESULTS In weighted intent-to-treat analyses, the probability of viral suppression increased 16% after initiating antidepressants [95% confidence interval = (1.12, 1.20)]. We observed an increase of 39 CD4T cells/μl after initiating antidepressants (30, 48). Both the frequency of remission from depression and PHQ-9 scores improved after antidepressant initiation. Comparative effectiveness estimates were null in all models. CONCLUSION Initiating antidepressant treatment was associated with improvements in depression, viral suppression, and CD4 T cells/μl, highlighting the health benefits of treating depression in PLWHA. Dual and single-action antidepressants had comparable effectiveness.
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Affiliation(s)
- Jon C Mills
- aDepartment of Epidemiology, University of North Carolina, Chapel Hill, North Carolina bDepartment of Behavioral Sciences and Social Medicine, Florida State University, Tallahassee cDepartment of Epidemiology and Medicine, University of Florida dDepartment of Health Services Research, Management and Policy, University of Florida, Gainesville, Florida eDepartment of Health Policy and Management, Indiana University, Indianapolis, Indiana fDepartment of Psychiatry, University of North Carolina, Chapel Hill, North Carolina, USA
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Kanmogne GD, Qiu F, Ntone FE, Fonsah JY, Njamnshi DM, Kuate CT, Doh RF, Kengne AM, Tagny CT, Nchindap E, Kenmogne L, Mbanya D, Cherner M, Heaton RK, Njamnshi AK. Depressive symptoms in HIV-infected and seronegative control subjects in Cameroon: Effect of age, education and gender. PLoS One 2017; 12:e0171956. [PMID: 28231258 PMCID: PMC5322951 DOI: 10.1371/journal.pone.0171956] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 01/27/2017] [Indexed: 12/03/2022] Open
Abstract
Depression is a leading cause of HIV/AIDS disease burden; it worsens health outcomes and quality of life. Addressing this problem requires accurate quantification of the extra burden of depression to HIV/AIDS in a given population, and knowledge of the baseline depression prevalence in the general population. There has been no previous study of depression in the general Cameroonian population. The current study attempts to address that important need. We used the Beck Depression Inventory-II to assess the prevalence and severity of depressive symptoms in 270 HIV-infected and seronegative Cameroonians. Univariate analyses showed a trend toward higher depressive symptoms among cases, compared to controls (p = 0.055), and among older subjects (>40 years), compared to younger subjects (≤40 years) (p = 0.059). Analysis of depression severity showed that 33.73% of cases had moderate-to-severe depressive symptoms, compared to 19.8% of controls (p<0.01). However, multivariable negative binomial regression analyses showed no effect of age, HIV status, CD4 levels, viral loads, ART, or opportunistic infections on the risk of depressive symptoms. Both univariate and multivariable regression analyses showed significantly higher risk of depressive symptoms among females compared to males; this was significant for both female controls and female cases. Female cases had significantly higher CD4 cell counts and lower viral loads, compared to males. Both univariate and multivariable regression analyses showed that lower education (≤10 years) was associated with increased risk of depressive symptoms. This study shows a high prevalence of depressive symptoms among seronegative controls and HIV-infected Cameroonians. Integrating care for mental disorders such as depression into primary health care and existing HIV/AIDS treatment programs in Cameroon may improve the wellbeing of the general population and could lower the HIV/AIDS burden.
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Affiliation(s)
- Georgette D. Kanmogne
- Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
- * E-mail:
| | - Fang Qiu
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Félicien E. Ntone
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Julius Y. Fonsah
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Dora M. Njamnshi
- HIV-Day Care Service, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Callixte T. Kuate
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Roland F. Doh
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Anne M. Kengne
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Claude T. Tagny
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | | | | | - Dora Mbanya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | - Mariana Cherner
- HIV Neurobehavioral Research Center, School of Medicine, University of California San Diego, San Diego, California, United States of America
| | - Robert K. Heaton
- Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, San Diego, California, United States of America
| | - Alfred K. Njamnshi
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
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Fonsah JY, Njamnshi AK, Kouanfack C, Qiu F, Njamnshi DM, Tagny CT, Nchindap E, Kenmogne L, Mbanya D, Heaton R, Kanmogne GD. Adherence to Antiretroviral Therapy (ART) in Yaoundé-Cameroon: Association with Opportunistic Infections, Depression, ART Regimen and Side Effects. PLoS One 2017; 12:e0170893. [PMID: 28141867 PMCID: PMC5283684 DOI: 10.1371/journal.pone.0170893] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2016] [Accepted: 01/12/2017] [Indexed: 12/30/2022] Open
Abstract
Following global efforts to increase antiretroviral therapy (ART) access in Sub-Saharan Africa, ART coverage among HIV-infected Cameroonians increased from 0% in 2003 to 22% in 2014. However, the success of current HIV treatment programs depends not only on access to ART, but also on retention in care and good treatment adherence. This is necessary to achieve viral suppression, prevent virologic failure, and reduce viral transmission and HIV/AIDS-related deaths. Previous studies in Cameroon showed poor adherence, treatment interruption, and loss to follow-up among HIV+ subjects on ART, but the factors that influence ART adherence are not well known. In the current cross-sectional study, patient/self-reported questionnaires and pharmacy medication refill data were used to quantify ART adherence and determine the factors associated with increased risk of non-adherence among HIV-infected Cameroonians. We demonstrated that drug side-effects, low CD4 cell counts and higher viral loads are associated with increased risk of non-adherence, and compared to females, males were more likely to forego ART because of side effects (p<0.05). Univariate logistic regression analysis demonstrated that subjects with opportunistic infections (on antibiotics) had 2.42-times higher odds of having been non-adherent (p<0.001). Multivariable analysis controlling for ART regimen, age, gender, and education showed that subjects with opportunistic infections had 3.1-times higher odds of having been non-adherent (p<0.0003), with significantly longer periods of non-adherence, compared to subjects without opportunistic infections (p = 0.02). We further showed that compared to younger subjects (≤40 years), older subjects (>40 years) were less likely to be non-adherent (p<0.01) and had shorter non-adherent periods (p<0.0001). The presence of depression symptoms correlated with non-adherence to ART during antibiotic treatment (r = 0.53, p = 0.04), and was associated with lower CD4 cell counts (p = 0.04) and longer non-adherent periods (p = 0.04). Change in ART regimen was significantly associated with increased likelihood of non-adherence and increased duration of the non-adherence period. Addressing these underlying risk factors could improve ART adherence, retention in care and treatment outcomes for HIV/AIDS patients in Cameroon.
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Affiliation(s)
- Julius Y. Fonsah
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Alfred K. Njamnshi
- Department of Neurology, Yaoundé Central Hospital, Yaoundé, Cameroon
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
| | - Charles Kouanfack
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- HIV-Day Care Service, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Fang Qiu
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE, United States of America
| | - Dora M. Njamnshi
- HIV-Day Care Service, Yaoundé Central Hospital, Yaoundé, Cameroon
| | - Claude T. Tagny
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | | | | | - Dora Mbanya
- Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon
- Yaoundé University Teaching Hospital, Yaoundé, Cameroon
| | - Robert Heaton
- Department of Psychiatry, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, United States of America
| | - Georgette D. Kanmogne
- Department of Pharmacology and Experimental Neuroscience, College of Medicine, University of Nebraska Medical Center, Omaha, NE, United States of America
- * E-mail:
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Thornicroft G, Deb T, Henderson C. Community mental health care worldwide: current status and further developments. World Psychiatry 2016; 15:276-286. [PMID: 27717265 PMCID: PMC5032514 DOI: 10.1002/wps.20349] [Citation(s) in RCA: 160] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
This paper aims to give an overview of the key issues facing those who are in a position to influence the planning and provision of mental health systems, and who need to address questions of which staff, services and sectors to invest in, and for which patients. The paper considers in turn: a) definitions of community mental health care; b) a conceptual framework to use when evaluating the need for hospital and community mental health care; c) the potential for wider platforms, outside the health service, for mental health improvement, including schools and the workplace; d) data on how far community mental health services have been developed across different regions of the world; e) the need to develop in more detail models of community mental health services for low- and middle-income countries which are directly based upon evidence for those countries; f) how to incorporate mental health practice within integrated models to identify and treat people with comorbid long-term conditions; g) possible adverse effects of deinstitutionalization. We then present a series of ten recommendations for the future strengthening of health systems to support and treat people with mental illness.
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Affiliation(s)
- Graham Thornicroft
- Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, SE5 8AF, UK
| | - Tanya Deb
- Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, SE5 8AF, UK
| | - Claire Henderson
- Centre for Global Mental Health, King's College London, Institute of Psychiatry, Psychology & Neuroscience, London, SE5 8AF, UK
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Günthard HF, Saag MS, Benson CA, del Rio C, Eron JJ, Gallant JE, Hoy JF, Mugavero MJ, Sax PE, Thompson MA, Gandhi RT, Landovitz RJ, Smith DM, Jacobsen DM, Volberding PA. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel. JAMA 2016; 316:191-210. [PMID: 27404187 PMCID: PMC5012643 DOI: 10.1001/jama.2016.8900] [Citation(s) in RCA: 480] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE New data and therapeutic options warrant updated recommendations for the use of antiretroviral drugs (ARVs) to treat or to prevent HIV infection in adults. OBJECTIVE To provide updated recommendations for the use of antiretroviral therapy in adults (aged ≥18 years) with established HIV infection, including when to start treatment, initial regimens, and changing regimens, along with recommendations for using ARVs for preventing HIV among those at risk, including preexposure and postexposure prophylaxis. EVIDENCE REVIEW A panel of experts in HIV research and patient care convened by the International Antiviral Society-USA reviewed data published in peer-reviewed journals, presented by regulatory agencies, or presented as conference abstracts at peer-reviewed scientific conferences since the 2014 report, for new data or evidence that would change previous recommendations or their ratings. Comprehensive literature searches were conducted in the PubMed and EMBASE databases through April 2016. Recommendations were by consensus, and each recommendation was rated by strength and quality of the evidence. FINDINGS Newer data support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count. Recommended optimal initial regimens for most patients are 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs. Recommendations for special populations and in the settings of opportunistic infections and concomitant conditions are provided. Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities. Laboratory assessments are recommended before treatment, and monitoring during treatment is recommended to assess response, adverse effects, and adherence. Approaches are recommended to improve linkage to and retention in care are provided. Daily tenofovir disoproxil fumarate/emtricitabine is recommended for use as preexposure prophylaxis to prevent HIV infection in persons at high risk. When indicated, postexposure prophylaxis should be started as soon as possible after exposure. CONCLUSIONS AND RELEVANCE Antiretroviral agents remain the cornerstone of HIV treatment and prevention. All HIV-infected individuals with detectable plasma virus should receive treatment with recommended initial regimens consisting of an InSTI plus 2 NRTIs. Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals. When used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. With these treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults.
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Affiliation(s)
- Huldrych F Günthard
- University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | | | | | - Carlos del Rio
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Joseph J Eron
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | | | - Jennifer F Hoy
- Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Paul E Sax
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston
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