Project YES! Youth Engaging for Success: A randomized controlled trial assessing the impact of a clinic-based peer mentoring program on viral suppression, adherence and internalized stigma among HIV-positive youth (15-24 years) in Ndola, Zambia

Effectiveness and acceptance of group therapy as a mental health intervention for people living with HIV in Africa - a scoping literature review

Mental health problems are highly prevalent among people living with HIV/AIDS (PLWHA), yet mental health care in African countries is scarce. There is growing interest in understanding the effect of group therapy delivery models and task-shifting to support mental health care in African settings. We conducted a scoping review following the PRISMA-ScR statement on group therapy in PLWHA in Africa. We searched PubMed/Medline, Embase, and Google Scholar for articles published before October 2023 on evidence for effectiveness and acceptance of group therapies in PLWHA, and evidence of task-shifting approaches. A narrative synthesis approach for data analysis was used. We included 17 studies, which comprised 26 different outcome measures across seven countries in sub-Sahara Africa. The majority (72%) of the assessed single outcomes demonstrated a positive impact of group therapy delivery models on outcome measures, particularly depression, alcohol use, overall functioning, and social support in sub-Sahara Africa. High acceptance was demonstrated by quantitative and qualitative approaches. Task shifting approaches generally were shown to be effective, cost-effective, and accepted, and may support burdened healthcare systems in rural settings. The current evidence, albeit scarce, supports the use of group therapy and task shifting in addressing mental health among PLWHA living in sub-Sahara Africa.

Socio-Behavioural Barriers to Viral Suppression in the Older Adult Population in Rural South Africa

South Africa has the largest share of people living with HIV in the world and this population is ageing. The social context in which people seek HIV care is often ignored. Apart from clinical interventions, socio-behavioural factors impact successful HIV care outcomes for older adults living with HIV. We use cross-sectional data linked with demographic household surveillance data, consisting of HIV positive adults aged above 40, to identify socio-behavioural predictors of a detectable viral load. Older adults were more likely to have a detectable viral load if they did not disclose their HIV positive status to close family members (aOR 2.56, 95% CI 1.89-3.46), resided in the poorest households (aOR 1.98, 95% CI 1.23-3.18), or were not taking medications other than ART (aOR 1.83, 95% CI 1.02-1.99) likely to have a detectable. Clinical interventions in HIV care must be supported by understanding the socio-behavioural barriers that occur outside the health facility. The importance of community health care workers in bridging this gap may offer more optimum outcomes for older adults ageing with HIV.

Identifying Best Practices for Increasing HIV Pre-exposure Prophylaxis (PrEP) Use and Persistence in the United States: A Systematic Review

A qualitative systematic review was conducted to evaluate pre-exposure prophylaxis (PrEP) interventions, describe characteristics of best practices for increasing PrEP use and persistence, and explore research gaps based on current PrEP interventions. We searched CDC's Prevention Research Synthesis (PRS) Project's cumulative HIV database (includes CINAHL, EMBASE, Global Health, MEDLINE, PsycInfo, and Sociological Abstracts) to identify PrEP intervention studies conducted in the U.S., published between 2000 and 2022 (last searched January 2023). Eligibility criteria include studies that evaluated PrEP interventions for persons testing negative for HIV infection, or for healthcare providers who prescribed PrEP; included comparisons between groups or pre/post; and reported at least one relevant PrEP outcome. Each eligible intervention was evaluated on the quality of study design, implementation, analysis, and strength of evidence (PROSPERO registration number: CRD42021256460). Of the 26 eligible interventions, the majority were focused on men who have sex with men (n = 18) and reported PrEP adherence outcomes (n = 12). Nine interventions met the criteria for Best Practices (i.e., evidence-based interventions, evidence-informed interventions). Five were digital health interventions while two implemented individual counseling, one offered motivational interviewing, and one provided integrated medical care with a PrEP peer navigator. Longer intervention periods may provide more time for intervention exposure to facilitate behavioral change, and engaging the community when developing, designing and implementing interventions may be key for effectiveness. For digital health interventions, two-way messaging may help participants feel supported. Research gaps included a lack of Best Practices for several populations (e.g., Black persons, Hispanic/Latino persons, persons who inject drugs, and women of color) and evidence for various intervention strategies (e.g., interventions for promoting provider's PrEP prescription behavior, peer support). These findings call for more collaborative work with communities to develop interventions that work and implement and disseminate Best Practices for increasing PrEP use and persistence in communities.

Systematic review and meta-analysis of interventions to promote medication adherence among children, adolescents, and young adults with medical conditions

OBJECTIVE

This meta-analysis examined the efficacy of adherence-promotion interventions for children, adolescents, and young adults prescribed a medication for > 90 days as part of a treatment regimen for a medical condition.

METHODS

A systematic literature review was conducted to identify randomized controlled trials of adherence-promotion interventions published between 2013 and 2023 and including children, adolescents, and/or young adults with a medical condition. A total of 38 articles representing 39 trials met inclusion criteria. A narrative synthesis was conducted to summarize included trials and a random-effects model was used to compute an overall intervention effect. Effect sizes by adherence outcome assessment methodology, participant age, and technology use were also computed.

RESULTS

Pediatric adherence-promotion interventions demonstrate a medium effect with those randomized to an intervention displaying greater improvements in medication adherence than those randomized to a comparator condition (SMD = 0.46, 95% CI: 0.31, 0.60, n = 37; 95% Prediction Interval: -0.32, 1.23).

CONCLUSIONS

Adherence interventions for children, adolescents, and young adults with medical conditions increase adherence.

Impact of a multicomponent navigation strategy on stigma among people living with HIV and Kaposi's sarcoma in Kenya: a qualitative analysis

Persons with HIV-associated Kaposi's sarcoma (KS) experience three co-existing stigmatizing health conditions: skin disease, HIV, and cancer, which contribute to a complex experience of stigmatization and to delays in diagnosis and treatment. Despite the importance of stigma among these patients, there are few proven stigma-reduction strategies for HIV-associated malignancies. Using qualitative methods, we explore how people with HIV-associated KS in western Kenya between August 2022 and 2023 describe changes in their stigma experience after participation in a multicomponent navigation strategy, which included 1) physical navigation and care coordination, 2) video-based education with motivational survivor stories, 3) travel stipend, 4) health insurance enrollment assistance, 5) health insurance stipend, and 6) peer mentorship. A purposive sample of persons at different stages of chemotherapy treatment were invited to participate. Participants described how a multicomponent navigation strategy contributed to increased knowledge and awareness, a sense of belonging, hope to survive, encouragement, and social support, which served as stigma mitigators, likely counteracting the major drivers of intersectional stigma in HIV-associated KS.

The Relationship between Serving as a Mentor and Depressive Symptoms among Sexual Minority Men in the MACS Healthy Aging Study

Sexual minority men (SMM) in the US are twice as likely to experience mental health challenges, including depressive symptoms, compared with their heterosexual counterparts. Having a like-mentor, or a sexual minority mentor, is associated with improved mental well-being among SMM mentees. However, few studies have explored the potential benefits to mentors. Using confirmatory factor analysis, we calculated a perceptions of mentoring score that encompasses experiences and beliefs regarding mentoring of SMM from the Healthy Aging Substudy of the Multicenter AIDS Cohort Study. We used a generalized estimating equations model to assess associations between perceptions of mentoring and clinically significant depressive symptoms adjusted for key covariates; models were also stratified by HIV serostatus. Among 1,246 men aged 40+ years, the strongest agreement was with the statement "I have encouraged people to be proud of their sexual orientation," for which 770 individuals (72%) indicated "Agree" or "Strongly Agree." Each unit increase in the mean perceptions of mentoring score was associated with 8% decreased odds of having clinically significant depressive symptoms (adjusted odds ratio: 0.92; 95% CI: 0.85-0.99). We show that SMM reported like-mentoring experiences and had positive mentoring beliefs, and that these were associated with a decreased odds of having depressive symptoms. Encouraging SMM to serve as like-mentors could be a way to counter depressive symptoms among this key population. There is a need for increased research regarding how mentoring programs can best be designed to benefit sexual minority mentees and mentors.

Factors Associated With Antiretroviral Adherence Among Youth Living With HIV

BACKGROUND

Youth living with HIV (YLH) have an increased risk for psychosocial stressors that can affect their antiretroviral (ARV) adherence. We examined factors associated with self-reported ARV adherence among YLH ages 12-24 years old.

SETTING

YLH (N = 147) were recruited in Los Angeles, CA, and New Orleans, LA from 2017 to 2020.

METHODS

YLH whose self-reported recent (30 days) ARV adherence was "excellent" or "very good" were compared with nonadherent YLH on sociodemographic, clinical, and psychosocial factors using univariate and multivariate analyses.

RESULTS

Participants were predominantly male (88%), and 81% identified as gay, bisexual, transgender, queer, or other. The mean duration on ARV was 27 months (range 0-237 months). Most YLH (71.2%) self-reported being adherent, and 79% of those who self-reported adherence were also virally suppressed (<200 copies/mL). Multivariate analysis indicated being adherent was significantly associated with white race [aOR = 8.07, confidence intervals (CI): 1.45 to 74.0], Hispanic/Latinx ethnicity [aOR = 3.57, CI: 1.16 to 12.80], more social support [aOR = 1.11, CI: 1.05 to 1.18], and being on ARV for a shorter duration [aOR = 0.99, CI: 0.97 to 0.99]. Mental health symptoms, substance use, age, and history of homelessness or incarceration were unrelated to adherence.

CONCLUSIONS

Enhancing efforts to provide support for adherence to non-white youth, and those with limited social support and who have been on ARV treatment longer, may help increase viral suppression among YLH.

The Association of Emotional Support, HIV Stigma, and Home Environment With Disclosure Efficacy and Perceived Disclosure Outcomes in Young People Living With HIV in Zambia: A Cross-Sectional Study

ABSTRACT

This study examined the association of various forms of social support, attitudes toward living at home, and HIV stigma experiences with HIV self-disclosure efficacy and perceived negative disclosure outcomes. We analyzed cross-sectional data from 120 young people with HIV (YPWH) aged 18-21 years receiving outpatient care in Eastern Province, Zambia. Perceived negative disclosure outcomes and disclosure self-efficacy were measured using an adapted version of the Adolescent HIV Disclosure Cognitions and Affect Scale. Explanatory variables included parental or caregiver support, emotional support, instrumental support, HIV stigma experiences, and attitudes toward living at home. Findings suggest that YPWH's confidence in their ability to self-disclose their HIV status and their assessment of negative outcomes associated with HIV disclosure are influenced by emotional support, experiences of HIV stigma, and the quality of the home environment.

The Effects of Peer Education on Treatment Adherence among Patients Receiving Hemodialysis: A Randomized Controlled Trial

Background

Non-adherence to treatments increases the rates of hemodialysis complications, hospitalization, and mortality. One strategy for adherence improvement is peer education. This study aimed to investigate the effects of peer education on treatment adherence among patients receiving hemodialysis.

Materials and Methods

This was a randomized controlled trial. Patients in the control group were provided just with routine care, and the intervention group received peer education. Treatment adherence was assessed both before and after the intervention via the End-Stage Renal Disease (ESRD) Adherence Questionnaire. Data analysis was conducted by the Chi-square, the Mann-Whitney U, the paired-sample t, and the independent-sample t tests.

Results

There were no significant between-group differences in terms of the pre-test mean scores of Adherence to regular attendance at hemodialysis sessions (t = 0.19, p = 0.85), Adherence to the prescribed medications (t = 0.46, p = 0.64), and Adherence to fluid restrictions (t = 0.24, p = 0.81). The same finding was observed after the intervention, except for the mean score of the adherence to fluid restrictions dimension which was significantly greater in the intervention group (t = 2.86, p = 0.006). Moreover, no significant changes were observed in the mean scores of treatment adherence dimensions in the control group. However, in the intervention group, the mean scores of the adherence to regular attendance at hemodialysis sessions (t = 3.79, p < 0.001) and the adherence to fluid restrictions dimensions were significantly greater than their pre-test values (t = 4.47, p < 0.001).

Conclusions

Education by peer groups improves the compliance of patients with regard to the consumption of fluids in the interval between two dialysis sessions.

Community level youth-led interventions to improve maternal-neonatal outcomes in low- and middle-income countries: A systematic review of randomised trials

Background

Evidence on the effectiveness of youth-led interventions for improving maternal-neonatal health and well-being of women and gender diverse childbearing people in low-income and middle-income countries (LMICs) is incomplete. We aimed to summarise the evidence on whether community level youth-led interventions can improve maternal and neonatal outcomes in LMICs.

Methods

We included experimental studies of youth-led interventions versus no intervention, standard care, or another intervention. Participants were women and gender diverse childbearing people during antepartum, intrapartum, and postpartum periods. MEDLINE, Embase, CINAHL, Global Health, Web of Science, and Cochrane Library, and grey literature were searched to January 2023. All interventions addressing and targeting maternal-neonatal health and well-being that were youth-led and community level were included. Primary outcomes of interest were maternal death and neonatal death. We excluded based on population, intervention, comparison, and outcome (PICO) and design. Two reviewers independently extracted key information from each included study and assessed risk of bias. Random-effects meta-analysis was performed where there were sufficient data. The certainty of evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE). A narrative synthesis was done for results that could not be pooled.

Results

Of the 8054 records retrieved, four trials (21 813 enrolled participants) met the inclusion criteria. The Cooperative for Assistance and Relieve Everywhere, Inc. (CARE) Community Score Card intervention compared to standard reproductive health services control did not significantly improve Antenatal Care coverage (difference-in-differences estimate β = 0.04; 95% confidence interval (CI) = -0.11, 0.18, P = 0.610; one study, low certainty of evidence). The multi-component social mobilisation interventions compared to standard of care had no effect on adolescent/youth pregnancy (adjusted odds ratio estimate = 1.08; 95% CI = 0.87, 1.33; three studies; low certainty of evidence).

Conclusions

Youth-led interventions in LMICs did not show a significant improvement in maternal outcomes. More studies are required to make more precise conclusions.

Registration

PROSPERO: CRD42021288798.

Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination

A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.

A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa

Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.

Lessons From Implementing Ask-Boost-Connect-Discuss, a Peer-Delivered Psychosocial Intervention for Young Mothers Living With HIV in Malawi, Tanzania, Uganda, and Zambia

Adolescent girls and young women in sub-Saharan Africa are at high risk of HIV, unintended pregnancy, and early motherhood. These intersecting risks can adversely affect their developmental trajectories and lifelong well-being. Because young mothers living with HIV in these settings experience high levels of stigma, shame, and isolation, tailored psychosocial intervention approaches for this group are critical yet unavailable. Enlisting young peer supporters may be a promising way to expand the reach of health services and enhance psychosocial well-being. To date, few peer-based interventions have targeted young mothers living with HIV. In 2019-2021, we codeveloped a peer-based, facility-embedded intervention package, Ask-Boost-Connect-Discuss (ABCD), with young peer supporters to address the psychosocial needs of young mothers living with HIV in Malawi, Tanzania, Uganda, and Zambia. We then analyzed programmatic data from ABCD to assess the feasibility of using young peers to deliver psychosocial support. Data sources included post-intervention interviews, focus groups, and written feedback from multiple stakeholders (participants, peer supporters, their supervisors, and clinic-based mentors), which were analyzed thematically. We organized our findings according to Bowen et al.'s feasibility framework. Findings spoke to the acceptability, practicality, and integration of the ABCD program. We found that young peer supporters were seen as acceptable program implementers; able to adopt responsive, engaging, and nonjudgmental approaches; and supported through training, technical skills development, and supervision, alongside purposeful facility integration. Importantly, we also found evidence reflecting the roles of demand and adaptation in program delivery (i.e., how peers responded to emerging participant needs or pivoted in their approach based on shifting circumstances). We conclude that considerations of intervention feasibility and/or program fidelity should be attuned to the dynamic qualities of young peer supporters as implementers and should extend beyond standard modes of assessment to consider intervention codevelopment and implementation as an iterative and adaptive process.

"Project YES! has given me a task to reach undetectable": Qualitative findings from a peer mentoring program for youth living with HIV in Zambia

The Project YES! clinic-based peer mentoring program was a randomized controlled trial (RCT) conducted among 276 youth from four HIV clinics to test the impact of the program on promoting HIV self-management and reducing internalized stigma among youth living with HIV (ages 15-24 years) in Ndola, Zambia. We conducted a qualitative sub-study involving in-depth interviews with 40 intervention youth participants (21 female, 19 male) to explore their experiences with Project YES! which included: an orientation meeting led by a healthcare provider, monthly individual and group counseling sessions over six months, and three optional caregiver group sessions. Using baseline RCT data, we used maximum variation sampling to purposively select youth by sex, age, change in virologic results between baseline and midline, and study clinic. A four-person team conducted thematic coding. Youth described their increased motivation to take their HIV care seriously due to Project YES!, citing examples of improvements in ART adherence and for some, virologic results. Many cited changes in behavior in the context of greater feelings of self-worth and acceptance of their HIV status, resulting in less shame and fear associated with living with HIV. Youth also attributed Project YES! with reducing their sense of isolation and described Project YES! youth peer mentors and peers as their community and "family." Findings highlight that self-worth and personal connections play a critical role in improving youths' HIV outcomes. Peer-led programs can help foster these gains through a combination of individual and group counseling sessions. Greater attention to the context in which youth manage their HIV, beyond medication intake, is needed to reach global HIV targets.

Better Together: acceptability, feasibility and preliminary impact of chronic illness peer support groups for South African adolescents and young adults

INTRODUCTION

Peer support can help navigate the isolation and psychological strain frequently experienced by youth living with chronic illness. Yet, data are lacking on the impact of providing support for youth living with mixed chronic conditions. We assessed the acceptability, feasibility and preliminary mental health impacts of a clinic-based peer support group for South African youth living with chronic illnesses, including HIV.

METHODS

This mixed-methods pilot study (September 2021-June 2022) enrolled 58 young patients, ages 13-24, at an urban hospital in Cape Town, South Africa. In-depth interviews elicited the perspectives of 20 young people in relation to their participation in the Better Together programme, a recurring clinic-based peer support group for patients with mixed chronic illnesses. Self-reported resilience, attitudes towards illness, stigma and mental health were captured via established measures. T-tests and multivariate analysis of variance compared psychosocial outcomes for 20 group participants and 38 control patients, controlling for socio-demographic characteristics at enrolment. Logistic regression analyses estimated the predicted probability of a positive depression or anxiety screening given peer group participation.

RESULTS

All interviewees valued being able to compare treatment regimens and disease management habits with peers living with different conditions. Adolescents living with HIV stated that understanding the hardships faced by those with other conditions helped them accept their own illness and lessened feelings of isolation. Compared to patients who did not participate in Better Together, those who attended ≥5 groups had statistically significantly higher individual-level resilience, a more positive attitude towards their illness(es), lower internalised stigma and a more positive self-concept. The probability of being screened positive for depression was 23.4 percentage points lower (95% CI: 1.5, 45.3) for Better Together participants compared to controls; the probability of a positive anxiety screening was 45.8 percentage points lower (95% CI: 18.1, 73.6).

CONCLUSIONS

Recurring, clinic-based peer support groups that integrate youth living with HIV and other chronic diseases are novel. Group sustainability will depend on the commitment of experienced peer leaders and providers, routine scheduling and transportation support. A fully powered randomised trial is needed to test the optimal implementation and causal mental health effects of the Better Together model.

Supportive couple relationships buffer against the harms of HIV stigma on HIV treatment adherence

INTRODUCTION

HIV stigma can impact couple relationships through stress or bring partners closer through shared experiences. Conversely, couple relationships may protect against the harms of stigma, including anticipated stigma on negative health outcomes. Yet few studies have assessed the potential link between HIV stigma, relationship dynamics, and antiretroviral therapy (ART) adherence. Using dyadic data from a cross-sectional study of Malawian couples living with HIV, we tested associations between anticipated stigma and: 1) relationship dynamics (e.g., trust, sexual satisfaction, communication) and partner support; and 2) self-reported ART adherence.

METHODS

Heterosexual couples (211 couples, 422 individuals) with at least one partner on ART were recruited from clinics in Zomba, Malawi. Partners completed separate surveys on anticipated stigma, relationship dynamics, and ART adherence. Linear mixed models evaluated associations between anticipated stigma and relationship dynamics, and whether associations varied by gender. Generalized estimating equation models tested for associations between anticipated stigma and high ART adherence (90-100% vs. < 90%) at the individual level, and whether they were moderated by relationship dynamics at the couple level.

RESULTS

Couples' relationship length averaged 12.5 years, 66.8% were HIV sero-concordant, and 95.6% reported high ART adherence. In multivariable models, sexual satisfaction (β = -0.22, 95%CI = -0.41;-0.03, p = 0.020) and partner social support (β = -0.02, 95%CI = -0.04;-0.01, p < 0.01) were negatively associated with anticipated stigma. Significant interaction effects showed that adherence is moderated in couples with higher partner support and sexual satisfaction such that adherence is lowest when anticipated stigma is high and social support is low, and that adherence is lowest when anticipated stigma is high and sexual satisfaction is low.

CONCLUSIONS

Increased anticipated stigma is most associated with lower ART non-adherence at lower levels of social support and sexual satisfaction. Conversely, supportive and fulfilling relationships may buffer the negative association between stigma and ART adherence. Couples' interventions that focus on improving communication and support systems within couples could reduce the negative impacts of anticipated stigma on couples living with HIV.

Interventions to Improve Adolescent HIV Care Outcomes

PURPOSE OF REVIEW

This review of recent studies evaluating interventions to improve HIV care outcomes among adolescents with HIV (AHIV) was conducted to provide a comprehensive overview of the recent evidence, highlight promising approaches, and suggest directions for future research.

RECENT FINDINGS

Our scoping review revealed 65 studies evaluating a variety of interventions and using a range of study designs at various stages of research. Effective approaches included community-based, integrated service delivery models with case management, trained community adolescent treatment supporters, and consideration of social determinants of health. Recent evidence also supports the feasibility, acceptability, and preliminary efficacy of other innovative approaches, including mental health interventions as well as technology-delivered approaches; however, more research is needed to build the evidence base for these interventions. Our review's findings suggest that interventions providing comprehensive, individualized support are essential to improving HIV care outcomes among adolescents. More research is needed to build the evidence base for such interventions and ensure effective, equitable implementation to support the global target of ending the AIDS epidemic by 2030.

A multilevel health system intervention for virological suppression in adolescents and young adults living with HIV in rural Kenya and Uganda (SEARCH-Youth): a cluster randomised trial

BACKGROUND

Social and cognitive developmental events can disrupt care and medication adherence among adolescents and young adults living with HIV in sub-Saharan Africa. We hypothesised that a dynamic multilevel health system intervention helping adolescents and young adults and their providers navigate life-stage related events would increase virological suppression compared with standard care.

METHODS

We did a cluster randomised, open-label trial of young individuals aged 15-24 years with HIV and receiving care in eligible clinics (operated by the government and with ≥25 young people receiving care) in rural Kenya and Uganda. After clinic randomisation stratified by region, patient population, and previous participation in the SEARCH trial, participants in intervention clinics received life-stage-based assessment at routine visits, flexible clinic access, and rapid viral load feedback. Providers had a secure mobile platform for interprovider consultation. The control clinics followed standard practice. The primary, prespecified endpoint was virological suppression (HIV RNA <400 copies per mL) at 2 years of follow-up among participants who enrolled before Dec 1, 2019, and received care at the study clinics. This trial is registered with ClinicalTrials.gov, NCT03848728, and is closed to recruitment.

FINDINGS

28 clinics were enrolled and randomly assigned (14 control, 14 intervention) in January, 2019. Between March 14, 2019, and Nov 26, 2020, we recruited 1988 participants at the clinics, of whom 1549 were included in the analysis (785 at intervention clinics and 764 at control clinics). The median participant age was 21 years (IQR 19-23) and 1248 (80·6%) of 1549 participants were female. The mean proportion of participants with virological suppression at 2 years was 88% (95% CI 85-92) for participants in intervention clinics and 80% (77-84) for participants in control clinics, equivalent to a 10% beneficial effect of the intervention (risk ratio [RR] 1·10, 95% CI 1·03-1·16; p=0·0019). The intervention resulted in increased virological suppression within all subgroups of sex, age, and care status at baseline, with greatest improvement among those re-engaging in care (RR 1·60, 95% CI 1·00-2·55; p=0·025).

INTERPRETATION

Routine and systematic life-stage-based assessment, prompt adherence support with rapid viral load testing, and patient-centred, flexible clinic access could help bring adolescents and young adults living with HIV closer towards a goal of universal virological suppression.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development, US National Institutes of Health.

Depression-Mediating Pathways From Household Adversity to Antiretroviral Therapy Nonadherence Among Children and Adolescents Living With HIV in Zambia: A Structural Equation Modeling Approach

BACKGROUND

In Zambia, half of children and adolescents living with HIV (CALWH) on antiretroviral therapy (ART) are virologically unsuppressed. Depressive symptoms are associated with ART nonadherence but have received insufficient attention as mediating factors in the relationship between HIV self-management and household-level adversities. We aimed to quantify theorized pathways from indicators of household adversity to ART adherence, partially mediated by depressive symptoms, among CALWH in 2 Zambian provinces.

SETTING

In July-September 2017, we enrolled 544 CALWH aged 5-17 years and their adult caregivers into a year-long prospective cohort study.

METHODS

At baseline, CALWH-caregiver dyads completed an interviewer-administered questionnaire, which included validated measures of recent (past 6 months) depressive symptomatology and self-reported past-month ART adherence (never versus sometimes or often missing medication doses). We used structural equation modeling with theta parameterization to identify statistically significant ( P < 0.05) pathways from household adversities (past-month food insecurity and caregiver self-reported health) to depression (modeled latently), ART adherence, and poor physical health in the past 2 weeks.

RESULTS

Most CALWH (mean age: 11 years, 59% female) exhibited depressive symptomatology (81%). In our structural equation model, food insecurity significantly predicted elevated depressive symptomatology ( ß = 0.128), which was associated inversely with daily ART adherence ( ß = -0.249) and positively with poor physical health ( ß = 0.359). Neither food insecurity nor poor caregiver health was directly associated with ART nonadherence or poor physical health.

CONCLUSIONS

Using structural equation modeling, we found that depressive symptomatology fully mediated the relationship between food insecurity, ART nonadherence, and poor health among CALWH.

Effect of Social Support Interventions on Adherence to Antiretroviral Therapy Among People Living with HIV: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis examined the effects of social support interventions (SSIs) on adherence to antiretroviral therapy (ART) among people living with HIV. We systematically searched Web of Science, PubMed/MEDLINE, Scopus, and Cochrane Library in September 9, 2020. English-language publications of randomized controlled trials (RCTs) in peer-reviewed journals were considered eligible. To estimate the effects of SSIs on adherence to ART, odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using random effects models. Subgroup analysis was used to investigate the sources of heterogeneity. Of 243 records identified, 17 controlled trials were included. The meta-analysis found significant and moderate effect size in the improvement of adherence to ART from SSIs. Subgroup analysis showed that the study design, follow up duration, source of social support, and year of publication significantly moderated the effect sizes in the meta-analysis. Our findings support the hypothesis that social support interventions can improve adherence to ART. Using various types and sources of social support, further research is needed to assess the effect of SSIs on adherence to ART across different settings.

Integrating Adolescent Mental Health into HIV Prevention and Treatment Programs: Can Implementation Science Pave the Path Forward?

Adolescent mental health (AMH) is a critical driver of HIV outcomes, but is often overlooked in HIV research and programming. The implementation science Exploration, Preparation, Implementation, Sustainment (EPIS) framework informed development of a questionnaire that was sent to a global alliance of adolescent HIV researchers, providers, and implementors working in sub-Saharan Africa with the aim to (1) describe current AMH outcomes incorporated into HIV research within the alliance; (2) identify determinants (barriers/gaps) of integrating AMH into HIV research and care; and (3) describe current AMH screening and referral systems in adolescent HIV programs in sub-Saharan Africa. Respondents reported on fourteen named studies that included AMH outcomes in HIV research. Barriers to AMH integration in HIV research and care programs were explored with suggested implementation science strategies to achieve the goal of integrated and sustained mental health services within adolescent HIV programs.

Understanding the experiences of caregivers of HIV-exposed children under five: A phenomenological inquiry

Background

Children born to mothers with HIV require special care from the womb to the postnatal period, and caregivers involved in their care face several challenges.

Objective

This study aimed to explore caregivers' experiences providing care for HIV-exposed children under five.

Methods

This study employed a phenomenological approach. Ten caregivers of HIV-exposed children living in Jakarta, Indonesia, were selected using snowball techniques. Online in-depth interviews were conducted to collect data from September 2021 to July 2022, and thematic analysis using Colaizzi's method was performed for data analysis.

Results

The study involved ten caregivers (nine females and one male) aged between 23 and 42 years. Seven of them were mothers who tested HIV-positive, while one was an adoptive father, one was a mother's sister, and one was an aunt of HIV-exposed children. The majority of them were housewives and had a low educational background. Three themes were generated: (i) disease-transmission foreboding, (ii) prejudice against mothers and children exposed to HIV, and (iii) seeking support.

Conclusion

Caring for HIV-exposed children poses emotional and physical challenges for caregivers, necessitating support from health professionals and peer groups. Nurses play essential roles in improving caregiver well-being and supporting optimal growth and development in HIV-exposed children under five by designing intervention programs. Furthermore, to enhance home-based HIV care in Indonesia, the government must implement social interventions that target families with limited resources.

Caring for Adolescents and Young Adults With Tuberculosis or at Risk of Tuberculosis: Consensus Statement From an International Expert Panel

Background:

Despite being a preventable and treatable disease, tuberculosis (TB) is a leading cause of death among young people globally. Each year, an estimated 1.8 million adolescents and young adults (AYAs; 10–24 years old) develop TB. In 2019, an estimated 161,000 AYAs died of the disease. AYAs have unique developmental, psychosocial, and healthcare needs, but these needs have been neglected in both TB care and research agendas. In order to improve outcomes in this age group, the specific needs of AYAs must be considered and addressed.

Methods:

Through a consensus process, an international panel of 34 clinicians, researchers, TB survivors, and advocates with expertise in child/adolescent TB and/or adolescent health proposed interventions for optimizing AYA engagement in TB care. The process consisted of reviewing the literature on TB in AYAs; identifying and discussing priority areas; and drafting and revising proposed interventions until consensus, defined a priori , was reached.

Results:

The panel acknowledged the dearth of evidence on best practices for identifying and managing AYAs with TB. The final consensus statement, based on expert opinion, proposes nine interventions to reform current practices that may harm AYA health and well-being, and nine interventions to establish high-quality AYA-centered TB services.

Conclusion:

AYA-specific interventions for TB care and research are critical for improving outcomes in this age group. In the absence of evidence on best practices, this consensus statement from an international group of experts can help address the needs of AYA with TB or at risk for TB.

HIV Epidemiology, Care, and Treatment Outcomes Among Student and Nonstudent Youths Living With HIV in Southwest China Between 1996 and 2019: Historical Cohort Study

BACKGROUND

Nearly one-third of new HIV infections occurred among youth in 2019 worldwide. Previous studies suggested that student youths living with HIV and nonstudent youths living with HIV might differ in some risk factors, transmission routes, HIV care, and disease outcomes.

OBJECTIVE

This study aimed to compare the HIV epidemic, disease outcomes, and access to care among student and nonstudent youths living with HIV aged 16 to 25 years in Guangxi, China.

METHODS

We performed a historical cohort study by extracting data on all HIV or AIDS cases aged 16 to 25 years in Guangxi, China, during 1996-2019 from the Chinese Comprehensive Response Information Management System of HIV or AIDS. We conducted analyses to assess possible differences in demographic and behavioral characteristics, HIV care, and disease outcomes between student and nonstudent youths living with HIV. Multivariate Cox regression was used to assess differences in mortality and virologic failure between student and nonstudent cases.

RESULTS

A total of 13,839 youths aged 16 to 25 years were infected with HIV during 1996-2019. Among them, 10,202 cases were infected through sexual contact, most of whom were men (n=5507, 54%); 868 (8.5%) were students, and 9334 (91.5%) were not students. The number of student youths living with HIV was lower before 2006 but gradually increased from 2007 to 2019. In contrast, the nonstudent cases increased rapidly in 2005, then gradually declined after 2012. Student cases were mainly infected through homosexual contact (n=614, 70.7% vs n=1447, 15.5%; P<.001), while nonstudent cases were more likely to be infected through heterosexual contact (n=7887, 84.5% vs n=254, 29.3%; P<.001). Moreover, nonstudent cases had a significantly lower CD4 count than student cases at the time of HIV diagnosis (332 vs 362 cells/μL; P<.001). Nonstudents also had a delayed antiretroviral therapy (ART) initiation compared to students (93 days vs 22 days; P<.001). Furthermore, the mortality rate of 0.4 and 1.0 deaths per 100 person-years were recorded for student and nonstudent youths with HIV, respectively. Overall, the mortality risk in nonstudent cases was 2.3 times that of student cases (adjusted hazard ratio [AHR] 2.3, 95% CI 1.2-4.2; P=.008). The virologic failure rate was 2.3 and 2.6 per 100 person-years among student and nonstudent youths living with HIV, respectively. Nonstudent cases had double the risk of virologic failure compared to student cases (AHR 1.9, 95% CI 1.3-2.6; P<.001).

CONCLUSIONS

Nonstudent youths living with HIV might face a low CD4 count at the time of HIV diagnosis, delayed ART initiation, and increased risk of death and virologic failure. Thus, HIV prevention and interventions should target youths who dropped out of school early to encourage safe sex and HIV screening, remove barriers to HIV care, and promote early ART initiation to curb the HIV epidemic among youths.

The effectiveness and sustainability of peer support interventions for persons living with HIV: a realist synthesis

BACKGROUND

Peer support is an important supplement to medical resources for persons living with HIV (PLHIV). However, previous studies have shown mixed results about intervention effects. It is necessary to explain the mechanism of peer support interventions' effectiveness and sustainability to help design more valid peer support interventions.

OBJECTIVE

To identify and explain the mechanisms that drive the effectiveness and maintain the sustainability of peer support interventions.

METHODS

A preliminary theoretical framework was developed through a scoping review of the grey literature and international project frameworks in five professional websites. We then refined the framework by systematically searching evidence in databases including PubMed, EMBASE, Web of Science, ProQuest, CINAHL, CNKI and Wanfang. Qualitative methods were used to generate codes and themes relating to the studies' context, mechanisms and outcomes. We checked chains of inference (connections) across extracted data and themes through an iterative process.

RESULTS

A total of 6345 articles were identified, and 52 articles were retained for final synthesis. The refined theoretical framework presents five areas of peer support, including informational support, instrumental support, emotional support, affiliational support and appraisal support; five types of outcomes that peer support can improve for PLHIV, including physiological outcomes, psychological outcomes, behavioural outcomes, cognitive outcomes and social outcomes; the effectiveness mechanism coding system from peer volunteers and the relationship between peer volunteers and PLHIV; and the sustainability mechanism coding system in terms of peer volunteers, PLHIV and study context.

CONCLUSIONS

Given that peer support has huge potential human resources, that is, all the qualified PLHIV, irreplaceable advantages in dealing with barriers to HIV-related discrimination and potential comprehensive benefits for PLHIV, it is necessary to develop and organise more peer support projects for PLHIV. Our study highlights that the expansion of peer support projects should be based on their effectiveness and sustainability.

PROSPERO REGISTRATION NUMBER

CRD42022339079.

Trajectories of re-engagement: factors and mechanisms enabling patient return to HIV care in Zambia

INTRODUCTION

While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engagement are essential to facilitate long-term care continuity.

METHODS

We conducted narrative, patient-centred, in-depth interviews between January and June 2019 with 20 PLWH in Lusaka, Zambia, who had disengaged and then re-engaged in HIV care, identified through electronic medical records (EMRs). We applied narrative analysis techniques, and deductive and inductive thematic analysis to identify engagement patterns and enablers of return.

RESULTS

We inductively identified five trajectories of care engagement, suggesting patterns in patient characteristics, experienced barriers and return facilitators that may aid intervention targeting including: (1) intermittent engagement;(2) mostly engaged; (3) delayed linkage after testing; (4) needs time to initiate antiretroviral therapy (ART); and (5) re-engagement with ART initiation. Patient-identified periods of disengagement from care did not always align with care gaps indicated in the EMR. Key, interactive re-engagement facilitators experienced by participants, with varied importance across trajectories, included a desire for physical wellness and social support manifested through verbal encouragement, facility outreach or personal facility connections and family instrumental support. The mechanisms through which facilitators led to return were: (1) the promising of living out one's life priorities; (2) feeling valued; (3) fostering interpersonal accountability; (4) re-entry navigation support; (5) facilitated care and treatment access; and (6) management of significant barriers, such as depression.

CONCLUSIONS

While preliminary, the identified trajectories may guide interventions to support re-engagement, such as offering flexible ART access to patients with intermittent engagement patterns instead of stable patients only. Further, for re-engagement interventions to achieve impact, they must activate mechanisms underlying re-engagement behaviours. For example, facility outreach that reminds a patient to return to care but does not affirm a patient's value or navigate re-entry is unlikely to be effective. The demonstrated importance of positive health facility connections reinforces a growing call for patient-centred care. Additionally, interventions should consider the important role communities play in fostering treatment motivation and overcoming practical barriers.

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

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

Clinical Application of a Peer Coaching Intervention to Enhance Self-Management for Adolescents and Young Adults With Inflammatory Bowel Disease

Objective

The purpose of this article is to characterize the current evidence base related to peer support interventions for adolescents and young adults (AYAs) with inflammatory bowel disease (IBD) and to describe a peer support program to enhance self-management for AYAs with IBD through a case study. There is strong theory and compelling evidence suggesting that AYAs with IBD could benefit from and are interested in receiving peer support to enhance self-management; however, literature on peer support interventions for AYAs with IBD is lacking.

Methods

This study (a) presents a topical review describing qualitative factors AYAs with IBD would seek in a peer support program as well as existing peer support programs for this population, (b) presents an innovative one-to-one peer support program targeting self-management through a case study, and (c) discusses clinical implications and directions for future research.

Results

Peer support offers a promising approach for AYAs with IBD that is feasible and acceptable to patient populations. However, results from the present topical review identified only two studies that examined peer support interventions for AYAs with IBD. The case study demonstrates how a theoretically driven program uses peer support to promote self-management and adaptive behavioral change.

Conclusions

The paucity of literature in this area reveals a critical opportunity for future research and clinical programming to improve existing practices by leveraging peer support. We present the application of an innovative mobile-based peer coaching intervention that has the potential to support AYAs with IBD in their self-management.

The Association of Perceived, Internalized, and Enacted HIV Stigma With Medication Adherence, Barriers to Adherence, and Mental Health Among Young People Living With HIV in Zambia

Few studies have examined the independent effects of different manifestations of HIV stigma experiences on health outcomes among youth living with HIV in low- and middle-income countries. We examined the association of internalized, enacted, and perceived HIV stigmas with medication adherence, self-esteem, depression, and barriers to adherence. Young people living with HIV aged 18-21 years (N = 120) were purposively sampled from two health facilities in Eastern Province, Zambia, and completed self-report measures. Results indicated heterogeneous associations. Internalized HIV stigma was positively associated with depression and negatively associated with adherence, adherence motivation, behavioral adherence skills, and self-esteem. Perceived stigma was negatively associated with self-esteem. No significant association was observed between enacted stigma and health outcomes. The complexity of HIV stigma requires a precise explication of the associations among different HIV stigma experiences and outcomes, which can inform the development of stigma reduction interventions targeting one or more stigma experiences.

Adolescent support club attendance and self-efficacy associated with HIV treatment outcomes in Tanzania

HIV treatment outcomes may be improved by ameliorating psychosocial challenges adolescents living with HIV (ALHIV) face. This analysis describes participation in existing facility-based adolescent clubs and the associations between club attendance, adolescent well-being and HIV treatment outcomes. Data were collected through interviews with a sub-sample of adolescents age 10-19 years and medical record abstraction of all adolescents attending HIV services at seven clinics in Tanzania. Independent variables included adolescent club attendance, self-esteem, self-efficacy, mental distress, social capital and other health utilization or HIV experience characteristics. Study outcomes included visit adherence, viral suppression (<1000 cp/ml), and retention. Of 645 adolescents attending HIV services, 75% attended clubs at least once with a median of eight club sessions attended over a two-year period. Mental distress was prevalent, with 67% of the adolescents scoring above a recognized cut-off of ≥5. Adolescents who attended 10 or more clubs, compared to those not attending any clubs over a two-year period were at an almost three-fold increased odds of having good visit adherence (odds ratio [OR] 2.72, 95% confidence interval [CI]: 1.25, 5.94). Club attendance was also associated with sustained retention in the following year: adolescents who attended some clubs (1-9) had three-times the odds of being retained (OR 3.01; 95%CI: 1.86, 4.87) while those who attended 10+ had over seven-times the odds (OR 7.29; 95%CI: 4.34, 12.22). Among the 154 adolescents who were interviewed, being in the top self-efficacy tertile was positively associated with viral suppression (OR 3.04, 95%CI: 1.08, 8.60) and retention (OR 4.44, 95%CI: 1.19, 17.40). Attending the HIV clinic with a guardian/treatment supporter (OR 3.29, 95%CI: 1.17, 9.22) was also associated with viral suppression. Self-efficacy, social capital and treatment support are associated with better health outcomes among adolescents. However, many ALHIV either never attended or did not regularly attend clubs.

How Do Psychosocial Interventions for Adolescents and Young People Living With HIV Improve Adherence and Viral Load? A Realist Review

PURPOSE

Psychosocial interventions have the potential to support adolescents and young people living with HIV (AYPLHIV) to achieve better HIV outcomes. However, more evidence is needed to understand which interventions are most effective, and the mechanisms driving how they work in practice.

METHODS

We used realist methodologies to generate statements based on evidence from intervention studies and linked evidence included in a systematic review of psychosocial interventions for AYPLHIV. Key data were extracted from available sources to generate cases, including context-mechanism-outcome pathways. Higher level themes were refined iteratively to create a mid-range theory of how these interventions may work.

RESULTS

From 26 resulting cases, 8 statements were crafted, grouped into 3 overarching categories, to describe how these interventions worked. Interventions were overall found to set off mechanisms to improve adherence when (1) responding to individual-level factors to support AYPLHIV (via incorporating agency and empowerment, personalized and/or contextualized approaches, and self-care skills); (2) tailoring delivery strategies to address specific needs (via diverse strategies, longer duration, and digital delivery); and (3) providing supportive resources (via peer and broader support, and structural support and integration into existing services).

DISCUSSION

A collection of diverse mechanisms may individually or collectively drive improved outcomes for AYPLHIV engaged in psychosocial interventions. Recommendations for integrating our findings into practice are discussed.

Internet-based peer support interventions for people living with HIV: A scoping review

Peer support interventions for people living with HIV and AIDS (PLWHA) are effective, but their associated time and material costs for the recipient and the health system make them reachable for only a small proportion of PLWHA. Internet-based interventions are an effective alternative for delivering psychosocial interventions for PLWHA as they are more accessible. Currently, no reviews are focusing on internet-based interventions with peer support components. This scoping review aims to map the existing literature on psychosocial interventions for PLWHA based on peer support and delivered through the internet. We conducted a systematic scoping review of academic literature following methodological guidelines for scoping reviews, and 28 articles met our criteria. We summarized the main characteristics of the digital peer support interventions for PLWHA and how they implemented peer support in a virtual environment. Overall the reported outcomes appeared promising, but more robust evidence is needed.

Adherence challenges and opportunities for optimizing care through enhanced adherence counseling for adolescents with suspected HIV treatment failure in Kenya

Background

Adolescents living with HIV (ALHIV) experience higher mortality and are more likely to have poor antiretroviral therapy (ART) adherence and unsuppressed viral load (VL) compared to adults. Enhanced adherence counseling (EAC) is a client-centered counseling strategy that aims to identify and address barriers to optimal ART use and can be tailored to the unique needs of adolescents. This study aimed to better understand adherence barriers among ALHIV with suspected treatment failure and their experience with EAC to inform future programming.

Methods

A qualitative study was conducted in Homa Bay and Turkana counties, Kenya in 2019 with adolescents and caregivers of children and adolescents living with HIV with suspected treatment failure after ≥6 months on ART and who had received ≥1 EAC sessions. Sixteen focus group discussions (FGDs) were conducted; five FGDs each were held with adolescents 12–14 years (n = 48) and 15–19 years (n = 36). Caregivers (n = 52) participated in six FGDs. Additionally, 17 healthcare workers providing pediatric/adolescent HIV services participated in in-depth interviews. Audio recordings were transcribed and translated from Kiswahili or Dholuo into English and coded using MAXQDA software. Data were thematically analyzed by participant group.

Results

Participants identified adolescents’ fear of being stigmatized due to their HIV status and their relationship with and level of support provided by caregivers. This underpinned and often undermined adolescents’ ART-taking behavior and progress towards more independent medication management. Adolescents were generally satisfied with EAC and perceived it to be important in improving adherence and reducing VL. However, problems were noted with facility-based, individual EAC counseling, including judgmental attitudes of providers and difficulties traveling to and keeping EAC clinic appointments. Participant-suggested improvements to EAC included peer support groups in addition to individual counseling, allowing for greater flexibility in the timing and location of sessions and greater caregiver involvement.

Conclusions

The findings provide opportunities to better tailor EAC interventions to promote improved ALHIV adherence and caregiver-supported disease management. Multi-prong EAC interventions that include peer-led and community approaches and target adolescent and caregiver treatment literacy may improve EAC delivery, address issues contributing to poor adherence, and position adolescents to achieve viral suppression.

Trial registration

ClinicalTrials.gov: NCT04915469.

Peer Approaches to Improve HIV Care Cascade Outcomes: a Scoping Review Focused on Peer Behavioral Mechanisms

PURPOSE OF REVIEW

There are three main components of peer-based approaches regardless of type: education, social support, and social norms. The purpose of this scoping review was to examine evidence in the literature among peer-based interventions and programs of components and behavioral mechanisms utilized to improve HIV care cascade outcomes.

RECENT FINDINGS

Of 522 articles found, 40 studies were included for data abstraction. The study outcomes represented the entire HIV care cascade from HIV testing to viral suppression. Most were patient navigator models and 8 of the studies included all three components. Social support was the most prevalent component. Role modeling of behaviors was less commonly described. This review highlighted the peer behavioral mechanisms that operate in various types of peer approaches to improve HIV care and outcomes in numerous settings and among diverse populations. The peer-based approach is flexible and commonly used, particularly in resource-poor settings.

Community Level Youth-Led Interventions to Improve Maternal-Neonatal Outcomes in Low- and Middle-Income Countries: Protocol for a Systematic Review

Introduction

On a global scale, women and childbearing people and neonates continue to die from preventable causes related to pregnancy or childbirth. Sustained and accelerated efforts are critical to improve maternal and neonatal health and well-being. Globally, youth are a growing population and have strength in their numbers. Youth are critical, key drivers of change in their communities. Young people hold the potential to affect positive change, and their meaningful engagement is important to improving maternal health and well-being in low- and middle-income countries.

Objectives

To assess the effects of community level youth-led interventions for improving maternal-neonatal health and well-being compared with no interventions or another intervention.

Methods

We will undertake a literature search that is comprehensive, complete, and exhaustive. This will include databases such as MEDLINE, EMBASE, and the Cochrane Library, as well as a grey literature search. In our systematic review, we will include experimental studies evaluating maternal-neonatal health and well-being associated with or because of the implementation of community level youth-led interventions. Participants will include women and childbearing people (of any age) during antepartum, intrapartum, and postpartum periods (up to 42 days postpartum). We will examine all interventions addressing and targeting maternal-neonatal health and well-being that are youth-led and community-based and aimed at the members of the community. Our comparators will be no intervention or another intervention. Our primary outcomes are maternal deaths and neonatal deaths. Our review will include only studies in low- and middle-income countries conducted in urban or rural areas. Ethics and Dissemination. Ethics approval is not required as we will use secondary data that is publicly available. There are no active participants in our study. We will involve key stakeholders and experts in maternal-neonatal health regarding dissemination and knowledge mobilization strategies. Our findings will be disseminated as an open access publication, be presented publicly, and defended as part of a doctoral thesis. This trial is registered with CRD42021288798.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

'So hurt and broken': A qualitative study of experiences of violence and HIV outcomes among Zambian youth living with HIV

Emerging data show associations between violence victimisation and negative HIV outcomes among youth in sub-Saharan Africa. We conducted in-depth interviews with adolescents and young adults living with HIV (aged 15-24 years) in Ndola, Zambia, to better understand this relationship. We purposively selected 41 youth (24 females, 17 males) with varied experiences of violence and virologic results. Analysis used thematic coding. Two-thirds of participants said violence affected their medication adherence, clinic attendance, and/or virologic results. They focused on the negative effects of psychological abuse from family members in homes and peers at schools, which were the most salient forms of violence raised, and sexual violence against females. In contrast, they typically depicted physical violence from caregivers and teachers as a standard discipline practice, with few impacts. Youth wanted HIV clinic settings to address verbal abuse and emotional maltreatment, alongside physical and sexual violence, including through peer mentoring. Violence - especially verbal and emotional forms - must be recognised as a potential barrier to HIV self-management among youth living with HIV in the region. Further testing of clinic, home, and school-based interventions may be critical to reducing levels of violence and improving HIV outcomes in this vulnerable but resilient population.Trial registration: ClinicalTrials.gov identifier: NCT04115813.

"It must start with me, so it started with me": A qualitative study of Project YES! youth peer mentor implementing experiences supporting adolescents and young adults living with HIV in Ndola, Zambia

BACKGROUND

Little is known about youth-led approaches to addressing HIV-related outcomes among adolescents and young adults (AYA) living with HIV. In response, Project YES! hired and trained youth living with HIV as peer mentors (YPMs) in four HIV clinics in Ndola, Zambia to hold meetings with 276 15-24-year-olds living with HIV. Within this randomized controlled trial, a qualitative sub-study was conducted to explore YPMs' implementing experiences.

METHODS

In-depth interviews were conducted with the eight YPMs (50% female) ages 21-26 years. YPMs were asked about their experiences working with clients, their feedback on program components, and what the experience meant to them personally and professionally. Interviews were audio-recorded, transcribed verbatim, and thematic analysis was performed.

RESULTS

YPMs connected with AYA clients by discussing shared struggles, modeling positive health behaviors, and establishing judgement-free environments. YPMs experienced powerful personal transformations in HIV-related health behaviors, conceptions of self, and plans for the future. Many expressed now seeing themselves as community leaders-"ambassadors", "game changers"-and "not just alone in this world." They described newfound commitments to reaching personal and professional goals. YPMs were adamant that Project YES! should expand so other HIV-positive AYA might benefit.

CONCLUSION

Well-trained and compensated YPMs who are integrated into HIV clinics can support AYA in unique and important ways due to their shared experiences. The transformational experience of becoming YPMs empowers youth to see themselves as role models and leaders. Future programs should engage youth living with HIV as partners in efforts to end the HIV epidemic.

Does Type of Social Support Influence Medication Adherence Among South African Adolescents Living With HIV? A Quantitative Analysis of Pilot Data

ABSTRACT

Adolescents living with HIV often experience worse medication adherence than older and younger individuals living with HIV. One factor that may mitigate poor adherence is social support. However, few studies have examined the influence of specific social support constructs on HIV outcomes like medication adherence. In response to this gap, we performed bivariate analyses using data from 104 adolescents living with HIV in Cape Town, South Africa to understand the relationship between three types of social support (emotional, informational, and instrumental support) and four HIV-related outcomes: adherence self-efficacy, last recorded CD4+ count, last recorded viral load, and adherence to clinic appointments in the past year. We found small positive associations between two social support types (emotional and informational support) and adherence self-efficacy, with no other statistically significant associations. In light of our small sample size, future studies should seek to understand the differential effects of specific types of social support on HIV-related outcomes to better inform interventions for adolescents living with HIV.

COVID-19 Ignited a Successful Growth Spurt in Pediatric HIV Differentiated Service Delivery Programming

Purpose of Review

Pediatric HIV differentiated service delivery (DSD) programming has historically lagged behind adult care despite WHO recommendations to include family-friendly alternatives for children and caregivers. This review explores the status of Pediatric DSD programming before the COVID-19 pandemic and then reviews published differentiated approaches that developed during the pandemic.

Recent Findings

Differentiated service delivery programming for adults living with HIV has increased worldwide, and patient outcomes from these programs have been positive. Pediatric DSD programming has lagged, with many children ineligible for multi-month refills. Despite WHO recommendations to space ART visits for children, limited access to viral load monitoring and a lack of viral suppression among children have left them out of this more convenient care option. Community ART groups historically were not structured to include children. Furthermore, after-hours clinics and teen clubs with ART dispensing have not reached the majority of CLHIV.

Summary

This review highlights programs that developed out of necessity during the lockdowns of the pandemic. Ingenuity and creativity forced programmers to provide care to their patients with less patient-clinician interaction. Children became eligible for multi-month dispensing as programs loosened eligibility criteria. Technology helped provide virtual psychological support, and unique ART delivery methods were developed. This rapid expansion or growth spurt, of pediatric DSD programming sped up the inclusion of children into care options that were less burdensome to the family. As we move away from the pandemic and adjust to a new standard, we will remain diligent in ensuring that CLHIV outcomes remain stable or perhaps, improve.

HIV Stigma Among a National Probability Sample of Adults with Diagnosed HIV-United States, 2018-2019

HIV stigma is a barrier to achieving the goals of the US Ending the HIV Epidemic initiative. We analyzed data from the Medical Monitoring Project (MMP) collected during 6/2018-5/2019 from 4050 US adults with diagnosed HIV. We reported national estimates of HIV stigma and assessed their associations with sociodemographic and clinical characteristics. Disclosure concerns and stigma related to negative public attitudes were common. Stigma was higher among younger age groups, women and transgender people, Black and Hispanic/Latino men and women, and Black and Hispanic/Latino men who have sex with men. Stigma was associated with lower antiretroviral therapy use and adherence, missed HIV care visits, and symptoms of depression or anxiety. The estimates presented provide a benchmark from which the nation can monitor its progress. The findings suggest the need for enhanced stigma-reduction efforts among specific groups and the importance of addressing stigma around disclosure and community attitudes.

Peer- and community-led responses to HIV: A scoping review

INTRODUCTION

In June 2021, United Nations (UN) Member States committed to ambitious targets for scaling up community-led responses by 2025 toward meeting the goals of ending the AIDS epidemic by 2030. These targets build on UN Member States 2016 commitments to ensure that 30% of HIV testing and treatment programmes are community-led by 2030. At its current pace, the world is not likely to meet these nor other global HIV targets, as evidenced by current epidemiologic trends. The COVID-19 pandemic threatens to further slow momentum made to date. The purpose of this paper is to review available evidence on the comparative advantages of community-led HIV responses that can better inform policy making towards getting the world back on track.

METHODS

We conducted a scoping review to gather available evidence on peer- and community-led HIV responses. Using UNAIDS' definition of 'community-led' and following PRISMA guidelines, we searched peer-reviewed literature published from January 1982 through September 2020. We limited our search to articles reporting findings from randomized controlled trials as well as from quasi-experimental, prospective, pre/post-test evaluation, and cross-sectional study designs. The overall goals of this scoping review were to gather available evidence on community-led responses and their impact on HIV outcomes, and to identify key concepts that can be used to quickly inform policy, practice, and research.

FINDINGS

Our initial search yielded 279 records. After screening for relevance and conducting cross-validation, 48 articles were selected. Most studies took place in the global south (n = 27) and a third (n = 17) involved youth. Sixty-five percent of articles (n = 31) described the comparative advantage of peer- and community-led direct services, e.g., prevention and education (n = 23) testing, care, and treatment programs (n = 8). We identified more than 40 beneficial outcomes linked to a range of peer- and community-led HIV activities. They include improved HIV-related knowledge, attitudes, intentions, self-efficacy, risk behaviours, risk appraisals, health literacy, adherence, and viral suppression. Ten studies reported improvements in HIV service access, quality, linkage, utilization, and retention resulting from peer- or community-led programs or initiatives. Three studies reported structural level changes, including positive influences on clinic wait times, treatment stockouts, service coverage, and exclusionary practices.

CONCLUSIONS AND RECOMMENDATIONS

Findings from our scoping review underscore the comparative advantage of peer- and community-led HIV responses. Specifically, the evidence from the published literature leads us to recommend, where possible, that prevention programs, especially those intended for people living with and disproportionately affected by HIV, be peer- and community-led. In addition, treatment services should strive to integrate specific peer- and community-led components informed by differentiated care models. Future research is needed and should focus on generating additional quantitative evidence on cost effectiveness and on the synergistic effects of bundling two or more peer- and community-led interventions.

Experiences with a violence and mental health safety protocol for a randomized controlled trial to support youth living with HIV

BACKGROUND

Safety protocols are an essential component of studies addressing violence and mental health but are rarely described in the published literature from Sub-Saharan Africa. We designed and implemented a safety protocol within Project YES! (Youth Engaging for Success), which enrolled 276 youth living with HIV (ages 15-24 years) in a randomized controlled trial of a peer-mentoring intervention across four HIV clinics in Ndola, Zambia.

METHODS

Youth who reported severe violence and/or suicidal thoughts on research surveys or during meetings with youth peer mentors (YPM) were referred to designated healthcare providers (HCP). We explored experiences with the safety protocol using: a) monitoring data of referrals, and b) in-depth interviews with youth (n = 82), HCP (n = 10), YPM (n = 8), and staff (n = 6). Descriptive statistics were generated and thematic analysis of coded transcripts and written memos performed.

RESULTS

Nearly half of youth enrolled (48% of females, 41% of males) were referred to a HCP at least once. The first referral was most often for sexual violence (35%) and/or suicidal ideation/depression (29%). All referred youth aged 15-17 years and over 80% of referred youth aged 18 + agreed to see a HCP. HCP referred 15% for additional services outside the clinic. Twenty-nine youth, all HCP, all YPM, and all staff interviewed discussed the safety protocol. Most youth felt "encouraged," "helped," "unburdened," and "relieved" by their meetings with HCP; some expressed concerns about meeting with HCP. The safety protocol helped HCP recognize the need to integrate care for violence and mental health with medication adherence support. HCP, YPM, and study staff raised implementation challenges, including youth choosing not to open up to HCP, time and resource constraints, deficiencies in HCP training, and stigma and cultural norms inhibiting referrals outside the clinic for emotional trauma and mental health.

CONCLUSIONS

Implementing a safety protocol within an HIV clinic-based research study is possible and beneficial for youth and HCP alike. Implementation challenges underscore that HCP in Zambia work in over-stretched healthcare systems. Innovative strategies must address deficiencies in training and resources within HIV clinics and gaps in coordination across services to meet the overwhelming need for violence and mental health services among youth living with HIV.

Feasibility, Acceptability and Preliminary Efficacy of Tikambisane ('Let's Talk to Each Other'): A Pilot Support Group Intervention for Adolescent Girls Living With HIV in Zambia

Background:

In Zambia, 84,959 adolescent girls and young women (AGYW) aged 15-24 are currently living with HIV. We explored the feasibility and acceptability of a 6-session, curriculum-based support group intervention designed to address key concerns of AGYW living with HIV.

Setting:

Urban Zambia

Methods:

Surveys and in-depth interviews were collected pre- and post-intervention from participants enrolled from 2 health facilities. Eight participant observations of sessions were conducted. Descriptive statistics at baseline were reported only for AGYW who participated in the intervention (N = 21), while analyses comparing baseline and endline outcome measures were restricted to participants who had data at both time points (N = 14).

Results:

Support groups were feasible to conduct and acceptable to participants. Co-facilitation by an adult counselor and peers living with HIV raised confidence about session content. Sessions on antiretroviral therapy (ART), disclosure and stigma, and grief and loss were most in demand. We did not observe significant differences in key outcome measures between baseline and follow-up. However, qualitative data supported the positive impact of the intervention on ART adherence and hope for the future following the intervention among our participants.

Conclusion:

A short-term, structured support group series holds promise for helping AGYW living with HIV safely navigate a complex time in their lives.

Psychosocial interventions for improving engagement in care and health and behavioural outcomes for adolescents and young people living with HIV: a systematic review and meta-analysis

INTRODUCTION

Adolescents and young people comprise a growing proportion of new HIV infections globally, yet current approaches do not effectively engage this group, and adolescent HIV-related outcomes are the poorest among all age groups. Providing psychosocial interventions incorporating psychological, social, and/or behavioural approaches offer a potential pathway to improve engagement in care and health and behavioural outcomes among adolescents and young people living with HIV (AYPLHIV).

METHODS

A systematic search of all peer-reviewed papers published between January 2000 and July 2020 was conducted through four electronic databases (Cochrane Library, PsycINFO, PubMed and Scopus). We included randomized controlled trials evaluating psychosocial interventions aimed at improving engagement in care and health and behavioural outcomes of AYPLHIV aged 10 to 24 years.

RESULTS AND DISCUSSION

Thirty relevant studies were identified. Studies took place in the United States (n = 18, 60%), sub-Saharan Africa (Nigeria, South Africa, Uganda, Zambia, Zimbabwe) and Southeast Asia (Thailand). Outcomes of interest included adherence to antiretroviral therapy (ART), ART knowledge, viral load data, sexual risk behaviours, sexual risk knowledge, retention in care and linkage to care. Overall, psychosocial interventions for AYPLHIV showed important, small-to-moderate effects on adherence to ART (SMD = 0.3907, 95% CI: 0.1059 to 0.6754, 21 studies, n = 2647) and viral load (SMD = -0.2607, 95% CI -04518 to -0.0696, 12 studies, n = 1566). The psychosocial interventions reviewed did not demonstrate significant impacts on retention in care (n = 8), sexual risk behaviours and knowledge (n = 13), viral suppression (n = 4), undetectable viral load (n = 5) or linkage to care (n = 1) among AYPLHIV. No studies measured transition to adult services. Effective interventions employed various approaches, including digital and lay health worker delivery, which hold promise for scaling interventions in the context of COVID-19.

CONCLUSIONS

This review highlights the potential of psychosocial interventions in improving health outcomes in AYPLHIV. However, more research needs to be conducted on interventions that can effectively reduce sexual risk behaviours of AYPLHIV, as well as those that can strengthen engagement in care. Further investment is needed to ensure that these interventions are cost-effective, sustainable and resilient in the face of resource constraints and global challenges such as the COVID-19 pandemic.

"Those People Motivate and Inspire Me to Take My Treatment." Peer Support for Adolescents Living With HIV in Cape Town, South Africa

Adherence to antiretroviral therapy (ART) and psychosocial support to manage stigma and disclosure is essential for adolescents living with HIV (ALHIV). Peer support groups can help ALHIV and their families live successfully with HIV. This qualitative study aimed to examine adolescent and caregiver perspectives on peer support groups. Three themes emerged: (1) peer support encouraged adherence to ART, (2) serostatus disclosure outside the family was perceived as difficult, and (3) the peer support group fostered fundamental and meaningful peer relationships for ALHIV. Caregivers felt peer support groups increased self-acceptance and adherence for ALHIV across 3 domains: (1) as motivation for families and adolescents, (2) to increase adolescent independence and maturity, and (3) to help adolescents accept their HIV status and live successfully with HIV. These data highlight the importance of psychosocial support groups for ALHIV and caregivers, illustrating the benefits of a safe space with trusted relationships and open communication.

"Adolescents do not only require ARVs and adherence counseling": A qualitative investigation of health care provider experiences with an HIV youth peer mentoring program in Ndola, Zambia

Introduction

Adolescents and young adults (AYAs) living with HIV face unique challenges and have poorer health outcomes than adults with HIV. Project YES! was a youth-led initiative to promote HIV self-management and reduce stigma among AYAs in four Ndola, Zambia clinics. Clinic health care providers (HCPs) were involved in multiple intervention aspects, including serving as expert resources during AYA and caregiver group meetings, facilitating resistance test-based AYA antiretroviral drug changes, meeting with participants referred through a safety protocol, and guiding a subset of participants’ physical transition from pediatric to adult clinic settings. This study aimed to understand HCP insights on facilitators and barriers to implementing Project YES! and scaling up a clinic-based, youth-focused program.

Methods

A trained interviewer conducted ten in-depth interviews with participating HCPs from November–December 2018 and analyzed data, identifying key themes. These themes were examined in terms of two implementation science outcomes–acceptability and feasibility–to inform scalability.

Results

HCPs found peer mentoring valuable for AYAs with HIV and the bimonthly caregiver meetings beneficial to AYA caregivers. HCPs voiced a desire for more involvement in specific processes related to patient clinical care, such as drug changes. HCPs’ experiences with the study safety protocol, including referrals for youth experiences of violence, shifted their views of AYAs and informed their understanding of key issues youth face. Considering this, many HCPs requested more resources to support AYAs’ varied needs. HCPs noted limited time and clinic space as implementation barriers but felt the program was valuable overall.

Conclusions

HCPs concluded youth peer mentoring was highly acceptable and feasible, supporting scale-up of youth-led interventions addressing the multi-faceted needs of AYAs living with HIV. Continued provider involvement in resistance test-based antiretroviral drug changes, considered in the context of health system and clinic policy, would enhance long-term success of the program at scale.

Past-Year Violence Victimization is Associated with Viral Load Failure Among HIV-Positive Adolescents and Young Adults

We examined the relationship between past-year violence victimization and viral load (VL) failure among consecutively-sampled male and female adolescents and young adults, aged 15-24, in four HIV clinics in Ndola, Zambia. Measures of past-year physical violence, psychological abuse, and forced sex were adapted from the ICAST-C and WHO Multi-Country Study. Using logistic regression, we derived associations between VL failure (≥ 1000 copies/mL) and: any victimization; cumulative victimization; and types and perpetrators of violence. Among 272 youth (59.2% female, 72.8% perinatally infected), 73.5% (n = 200) experienced past-year violence and 36.8% (n = 100) had VL failure. Higher odds of VL failure were observed for participants who reported high frequency of any violence versus no violence victimization (adjusted OR, aOR: 3.58; 95% CI 1.14-11.27), high frequency of psychological abuse versus no psychological abuse (aOR: 3.32; 95% CI 1.26-8.70), any versus no violence from a family member other than a parent/caregiver for physical violence (aOR: 2.18, 95% CI 1.05-4.54) and psychological abuse (aOR: 2.50; 95% CI 1.37-4.54), and any versus no physical violence from a friend/peer (aOR: 2.14, 95% CI 1.05-4.36). Past-year violence victimization was associated with VL failure when considering the frequency, type, and perpetrator of violence. Programs addressing violence among youth living with HIV may be critical to improving viral suppression and preventing onward transmission.