A mixed methods approach to adapting and evaluating the functional assessment of HIV infection (FAHI), Swahili version, for use with low literacy populations

Neurocognitive outcomes of children exposed to and living with HIV aged 3-5 years in Kilifi, Kenya

Introduction

Globally, 1.7 million children are living with HIV, with the majority of them residing in sub-Saharan Africa. Due to reduced rates of vertical transmission of HIV, there is an increasing population of children born to HIV-infected mothers who remain uninfected. There is a growing concern around the development of these children in the antiretroviral therapy era. This study examined the neurocognitive outcomes of children who are HIV-exposed infected (CHEI), HIV-exposed uninfected (CHEU) and HIV-unexposed uninfected (CHUU) and explored the relationship between child neurocognitive outcomes and child's biomedical and caregivers' psychosocial factors.

Methods

CHEI, CHUU and CHEU aged 3-5 years and their caregivers were recruited into the study. Neurocognitive outcomes were assessed using a validated battery of assessments. One-way analysis of variance and covariance (ANOVA and ANCOVA) were used to evaluate differences among the three groups by neurocognitive outcomes. Linear regression models were used to investigate the association between child neurocognitive outcomes and biomedical factors (nutritional status, HIV disease staging) and caregivers' psychosocial factors [symptoms of common mental disorders (CMDs) and parenting behaviour].

Results

The study included 153 children and their caregivers: 43 (28.1%) CHEI, 52 (34.0%) CHEU and 58 (39.9%) CHUU. ANOVA and ANCOVA revealed a significant difference in cognitive ability mean scores across the child groups. Post hoc analysis indicated that CHEU children had higher cognitive ability mean scores than the CHUU group. Better nutritional status was significantly associated with higher cognitive ability scores (β = 0.68, 95% CI [0.18-1.18], p = 0.008). Higher scores of CMDs were negatively associated with inhibitory control (β = -0.28, 95% CI [-0.53 to 0.02], p = 0.036). While comparing HIV stages 2 and 3, large effect sizes were seen in working memory (0.96, CI [0.08-1.80]) and cognitive ability scores (0.83 CI [0.01-1.63]), indicating those in stage 3 had poor performance.

Conclusions

Neurocognitive outcomes were similar across CHEI, CHEU and CHUU, although subtle differences were seen in cognitive ability scores where CHEU had significantly higher cognitive mean scores than the CHUU. Well-designed longitudinal studies are needed to ascertain these findings. Nonetheless, study findings underscore the need for strategies to promote better child nutrition, mental health, and early antiretroviral therapy initiation.

HIV-Specific Reported Outcome Measures: Systematic Review of Psychometric Properties

BACKGROUND

The management of people living with HIV and AIDS is multidimensional and complex. Using patient-reported outcome measures (PROMs) has been increasingly recognized to be the key factor for providing patient-centered health care to meet the lifelong needs of people living with HIV and AIDS from diagnosis to death. However, there is currently no consensus on a PROM recommended for health care providers and researchers to assess health outcomes in people living with HIV and AIDS.

OBJECTIVE

The purpose of this systematic review was to summarize and categorize the available validated HIV-specific PROMs in adults living with HIV and AIDS and to assess these PROMs using the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) methodology.

METHODS

This systematic review followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A literature search of 3 recommended databases (PubMed, Embase, and PsychINFO) was conducted on January 15, 2021. Studies were included if they assessed any psychometric property of HIV-specific PROMs in adults living with HIV and AIDS and met the eligibility criteria. The PROMs were assessed for 9 psychometric properties, evaluated in each included study following the COSMIN methodology by assessing the following: the methodological quality assessed using the COSMIN risk of bias checklist; overall rating of results; level of evidence assessed using the modified Grading of Recommendations, Assessment, Development, and Evaluation approach; and level of recommendation.

RESULTS

A total of 88 PROMs classified into 8 categories, assessing the psychometric properties of PROMs for adults living with HIV and AIDS, were identified in 152 studies including 79,213 people living with HIV and AIDS. The psychometric properties of most included PROMs were rated with insufficient evidence. The PROMs that received class A recommendation were the Poz Quality of Life, HIV Symptom Index or Symptoms Distress Module of the Adult AIDS Clinical Trial Group, and People Living with HIV Resilience Scale. In addition, because of a lack of evidence, recommendations regarding use could not be made for most of the remaining assessed PROMs (received class B recommendation).

CONCLUSIONS

This systematic review recommends 3 PROMs to assess health outcomes in adults living with HIV and AIDS. However, all these PROMs have some shortcomings. In addition, most of the included PROMs do not have sufficient evidence for assessing their psychometric properties and require a more comprehensive validation of the psychometric properties in the future to provide more scientific evidence. Thus, our findings may provide a reference for the selection of high-quality HIV-specific PROMs by health care providers and researchers for clinical practice and research.

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

BACKGROUND

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

AIMS

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Beyond viral suppression: Quality of life among stable ART clients in a differentiated service delivery intervention in Tanzania

BACKGROUND

With antiretroviral therapy, more people living with HIV (PLHIV) in resource-limited settings are virally suppressed and living longer. WHO recommends differentiated service delivery (DSD) as an alternative, less resource-demanding way of expanding HIV services access. Monitoring client's health-related quality of life (HRQoL) is necessary to understand patients' perceptions of treatment and services but is understudied in sub-Saharan Africa. We assessed HRQoL among ART clients in Tanzania accessing two service models.

METHODS

Cross-sectional survey from May-August 2019 among stable ART clients randomly sampled from clinics and clubs in the Shinyanga region providing DSD and clinic-based care. HRQoL data were collected using a validated HIV-specific instrument-Functional Assessment of HIV infection (FAHI), in addition to socio-demographic, HIV care, and service accessibility data. Descriptive analysis of HRQoL, logistic regression and a stepwise multiple linear regression were performed to examine HRQoL determinants.

RESULTS

629 participants were enrolled, of which 40% accessed DSD. Similar HRQoL scores [mean (SD), p-value]; FAHI total [152.2 (22.2) vs 153.8 (20.6), p 0.687] were observed among DSD and clinic-based care participants. Accessibility factors contributed more to emotional wellbeing among DSD participants compared to the clinic-based care participants (53.4% vs 18.5%, p =  < 0.001). Satisfactory (> 80% of maximum score) HRQoL scoring was associated with (OR [95% CI], p-value) being male (2.59 [1.36-4.92], p 0.004) among clinic participants and with urban residence (4.72 [1.70-13.1], p 0.001) among DSD participants.

CONCLUSIONS

Similar HRQoL was observed in DSD and clinic-based care. Our research highlights focus areas to identify supporting interventions, ultimately optimizing HRQoL among PLHIV.

Yes, no, maybe so: the importance of cognitive interviewing to enhance structured surveys on respectful maternity care in northern India

Quantitative survey findings are important in measuring health-related phenomena, including on sensitive topics such as respectful maternity care (RMC). But how well do survey results truly capture respondent experiences and opinions? Quantitative tool development and piloting often involve translating questions from other settings and assessing the mechanics of implementation, which fails to deeply explore how respondents understand survey questions and response options. To address this gap, we conducted cognitive interviews on survey questions (n = 88) adapted from validated RMC instruments used in Ethiopia, Kenya and elsewhere in India. Cognitive interviews with rural women (n = 21) in Madhya Pradesh, India involved asking the respondent the survey question, recording her response, then interviewing her about what the question and response options meant to her. We analysed the interviews to revise the tool and identify question failures, which we grouped into six areas: issues with sequencing, length and sensitivity; problematic response options; inappropriate vocabulary; temporal and spatial confusion; accessing different cognitive domains; and failure to resonate with the respondent’s worldview and reality. Although women tended to provide initial answers to the survey questions, cognitive interviews revealed widespread mismatch between respondent interpretation and question intent. Likert scale response options were generally incomprehensible and questions involving hypothetical scenarios could be interpreted in unexpected ways. Many key terms and concepts from the international RMC literature did not translate well and showed low resonance with respondents, including consent and being involved in decisions about one’s care. This study highlights the threat to data quality and the validity of findings when translating quantitative surveys between languages and cultures and showcases the value of cognitive interviews in identifying question failures. While survey tool revision can address many of these issues, further critical discussion is needed on the use of standardized questions to assess the same domains across contexts.

Correlates of health-related quality of life among adults receiving combination antiretroviral therapy in coastal Kenya

Background

Health-related quality of life (HRQoL) is an important metric of perceived wellbeing in people living with HIV/AIDS (PLWHA). However, research on HRQoL among PLWHA in sub-Saharan Africa is limited. This study investigates factors associated with HRQoL among PLWHA in Kilifi, coast of Kenya.

Methods

Between February and April 2018, 450 adults living with HIV and on combined antiretroviral therapy (cART) between 18 to 60 years were sequentially recruited from an HIV-specialized clinic. The Functional Assessment of HIV Infection (FAHI) questionnaire, previously adapted for assessing HRQoL in this setting, was slightly modified and administered to participants alongside other measures of sociodemographic, health and treatment characteristics in a face-to-face interview.

Results

Linear regression analyses indicated that depressive symptoms, HIV-related stigma, non-disclosure of HIV status, living alone, clinic inaccessibility, and presence of any current opportunistic infection were significantly associated with lower HRQoL scores at both the FAHI overall and sub-scale level. Higher physician empathy, male sex, and higher body mass index were significantly associated with better HRQoL scores at both FAHI overall and sub-scale level. Age and longer duration on cART were significantly associated with better HRQoL only at the sub-scale level.

Conclusions

Interventions aimed at reducing depressive symptoms and HIV stigma, making HIV-related services more accessible, addressing opportunistic infections, strengthening social support systems, serostatus disclosure and put in place caring, respectful, and compassionate model of care are necessary to improve the HRQoL of PLWHA.

Prototype Development, Usability, and Preference of a Culturally-relevant Pictorial Aid to Facilitate Comprehension of Likert-type Levels of Agreement in Caregivers of Children Living With HIV in Ghana

Pictorial illustrations of Likert-type scales are culturally useful and may reduce error associated with usage of Westernized self-report measures in low- and middle-income countries. Pictorial illustrations can be encounter-specific decision aids in populations with low literacy or English proficiency. In an unanticipated finding from the SANKOFA study, caregivers of children living with human immunodeficiency virus experienced challenges comprehending Likert-type scales. A cross-sectional, qualitative study was conducted with a SANKOFA participant subset (n = 30) in Ghana. Using an informatics-based formative design approach, we developed a culturally-relevant pictorial aid to assess usability and preference when compared to a Likert-type self-report measure. Ninety percent (n = 27) of substudy participants preferred the pictorial of a traditional Bolga basket over a shallow basket. Forty-three percent (n = 13) preferred the pictorial aid over the Likert-type measure. Fifty percent reported the pictorial aid was easy to use. Fifty-seven percent preferred the Likert-type measure, potentially because English proficiency is regarded in Ghana as a means of upward social and financial mobility. Such cultural norms may have contributed to the lack of consensus and must be considered for pictorial aids to be meaningful. Pictorial aids have been designed for use in clinical and research settings. They reduce barriers associated with lower textual literacy while facilitating comprehension and decision-making.

The development of an ultra-short, maternal mental health screening tool in South Africa

PURPOSE

The burden of common perinatal mental disorders (CPMD) in low-and-middle-income countries is substantially higher than high-income countries, with low levels of detection, service provision and treatment in resource-constrained settings. We describe the development of an ultra-short screening tool to detect antenatal depression, anxiety disorders and maternal suicidal ideation.

METHODS

A sample of 376 women was recruited at a primary-level obstetric clinic. Five depression and anxiety symptom-screening questionnaires, demographics and psychosocial risk questionnaires were administered. All participants were assessed with the Mini-International Neuropsychiatric Interview (MINI), a structured, diagnostic interview. Screening tool items were analysed against diagnostic data using multiple logistic regression and receiver operating curve (ROC) analysis.

RESULTS

The prevalence of MINI-defined major depressive episode (MDE) and/or anxiety disorders was 33%. Overall, 18% of participants expressed suicidal ideation and behaviour, 54% of these had no depression or anxiety diagnosis. Multiple logistic regression identified four screening items that were independently predictive of MDE and anxiety disorders, investigating depressed mood, anhedonia, anxiety symptoms and suicidal ideation. ROC analysis of these combined items yielded an area under the curve of 0.83 (95% CI 0.78-0.88). A cut-off score of 2 or more offered a sensitivity of 78% and specificity of 82%.

CONCLUSION

This novel screening tool is the first measure of CPMD developed in South Africa to include depressed mood, anxiety symptoms and suicidal ideation. While the tool requires further investigation, it may be useful for the early identification of mental health symptoms and morbidity in the perinatal period.

Aging, Health, and Quality of Life for Older People Living With HIV in Sub-Saharan Africa: A Review and Proposed Conceptual Framework

OBJECTIVE

The number of people living with HIV (PLWH) over 50 years old in sub-Saharan Africa is predicted to triple in the coming decades, to 6-10 million. Yet, there is a paucity of data on the determinants of health and quality of life for older PLWH in the region.

METHODS

A review was undertaken to describe the impact of HIV infection on aging for PLWH in sub-Saharan Africa.

RESULTS

We (a) summarize the pathophysiology and epidemiology of aging with HIV in resource-rich settings, and (b) describe how these relationships might differ in sub-Saharan Africa, (c) propose a conceptual framework to describe determinants of quality of life for older PLWH, and (d) suggest priority research areas needed to ensure long-term gains in quality of life for PLWH in the region.

CONCLUSIONS

Differences in traditional, lifestyle, and envirnomental risk factors, as well as unique features of HIV epidemiology and care delivery appear to substantially alter the contribution of HIV to aging in sub-Saharan Africa. Meanwhile, unique preferences and conceptualizations of quality of life will require novel measurement and intervention tools. An expanded research and public health infrastructure is needed to ensure that gains made in HIV prevention and treamtent are translated into long-term benefits in this region.