Prevalence of physical and sexual violence and psychological abuse among adolescents and young adults living with HIV in Zambia

Prevalence and Correlates of Intimate Partner Violence Victimization Among Urban Adolescents and Young Adults Living With Perinatally-Acquired HIV Infection or Perinatal HIV Exposure

INTRODUCTION

Because of privacy and ethical concerns, the data cannot be made available because of the sensitivity of the HIV data and the relatively small sample and ease of identifying people if a few demographics are known.Few studies have examined intimate partner violence (IPV) victimization among adolescents and young adults (AYAs) with perinatally acquired HIV-infection (PHIV) or perinatal HIV exposure without infection (PHEU) in the United States. The purpose of this study was to (1) estimate lifetime and past-year prevalence of IPV victimization and (2) examine correlates of IPV victimization by subtype (physical, psychological, and sexual) and severity (low, moderate, and severe).

METHODS

Data came from the sixth interview of an ongoing New York City-based longitudinal study of primarily Black and Latinx AYAPHIV and AYAPHEU. We examined 232 participants (142 PHIV; 90 PHEU) who had reported having been in at least 1 romantic relationship. We used logistic regression models to explore the association between IPV victimization outcomes and select sociodemographic, psychiatric, and environmental factors. Models were adjusted for age, gender, race, ethnicity, and HIV status.

RESULTS

IPV victimization prevalence was 84% for lifetime and 65% for the past year. There were no differences in IPV victimization prevalence by PHIV status. Having a recent substance use disorder, reporting higher levels of neighborhood stress, and being male were all positively associated with at least 1 IPV outcome; stronger familial relationships exhibited a protective effect.

CONCLUSIONS

The present study suggests that the prevalence of IPV victimization among AYAPHIV and AYAPHEU is exceedingly high that warrants targeted IPV screening and programming for this population.

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.

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.

Which groups are most affected by sexual violence? A disaggregated analysis by sex, age, and HIV-status of adolescents living in South Africa

BACKGROUND

Estimates on sexual violence (SV) among adolescents are rarely disaggregated by key indicators.

OBJECTIVE

We examine the independent effects of sex, age, HIV status and mode of HIV acquisition on the exposure to SV using generalised estimating equations models and proportional hazard model.

PARTICIPANT AND SETTING

Data from a 4-year prospective cohort study of 1447 adolescents (ages 10-19, 57% girls, 76% living with HIV) in South Africa.

METHODS

We describe the lifetime prevalence of three forms of SV: non-contact (unwanted showing of private parts), contact (coerced sexual debut, attempted and completed forced penetrative or oral sex,) and exploitative (sex in exchange for goods/money).

RESULTS

Overall, 23.9% (95%CI = 21.7%-26.1%) reported exposure to SV at some point in their lives: non-contact = 5.7%, contact = 9.0% and exploitative = 15.8%. While girls reported higher rates of exploitative (18.4% vs 12.3%; p < 0.001) and contact SV (12.3% vs 4.6%; p < 0.001), there were no differences in levels of non-contact SV by sex (6.5% vs 4.6%; p = 0.086). Exposure to any SV doubled in late adolescence (10-14 years = 7.0% vs ≥15 years = 31.7%; aIRR = 2.07; 95%CI = 1.82-2.37). Though level of SV were comparable between those living with HIV and those HIV-uninfected (22.9% vs 26.2%; p = 0.182), adolescents who recently acquired HIV were twice as likely to experience SV compared to adolescents who perinatally acquired HIV (42.3% vs 15.7%; aIRR = 2.03; 95%CI = 1.73-2.39). This association persisted when analysis was restricted to incidence SV during follow-up (aIRR = 1.53; 95%CI = 1.23-2.10).

CONCLUSION

Exposure to SV was high for both sexes, increased with age and more prevalent among adolescents who recently acquired HIV. SV prevention and response services must also be offered to boys and strengthened in HIV care services.

Depressive symptoms and HIV risk behaviours among adolescents enrolled in the HPTN071 (PopART) trial in Zambia and South Africa

BACKGROUND

Mental health is a critical and neglected public health problem for adolescents in sub-Saharan Africa. In this paper we aim to determine the prevalence of depressive symptoms and the association with HIV risk behaviours in adolescents aged 15-19 years in Zambia and SA.

METHODS

We conducted a cross-sectional survey from August-November 2017 in seven control communities of HPTN 071 (PopART) trial (a community-randomised trial of universal HIV testing and treatment), enrolling approximately 1400 eligible adolescents. HIV-status was self-reported. Depressive symptoms were measured with the Short Mood and Feelings Questionnaire (SMFQ), with a positive screen if adolescents scored ≥12. We fitted a logistic regression model to identify correlates of depressive symptoms with subgroup analyses among those who self-reported ever having had sex, by gender and country.

RESULTS

Out of 6997 households approached, 6057 (86.6%) were enumerated. 2546 adolescents were enumerated of whom 2120 (83.3%) consented to participate and were administered the SMFQ. The prevalence of depressive symptoms was 584/2120 (27.6%) [95%CI: 25.7%-29.5%]. Adolescents in SA were less likely to experience depressive symptoms (Adjusted Odds Ratio [AOR] = 0.63 (95% CI: 0.50, 0.79), p-value<0.0001). Female adolescents (AOR = 1.46 (95% CI: 1.19, 1.81), p-value<0.0001); those who reported ever having sex and being forced into sex (AOR = 1.80 (95% CI: 1.45, 2.23), p-value<0.001) and AOR = 1.67 (95% CI: 0.99, 2.84); p-value = 0.057 respectively) were more likely to experience depressive symptoms. Among 850 (40.1%) adolescents who self-reported to ever having had sex; those who used alcohol/drugs during their last sexual encounter were more likely to experience depressive symptoms (AOR = 2.18 (95% CI: 1.37, 3.47); p-value = 0.001), whereas those who reported using a condom were less likely to experience depressive symptoms (AOR = 0.74 (95% CI: 0.55, 1.00); p-value = 0.053).

CONCLUSION

The prevalence of depressive symptoms among adolescents ranged from 25-30% and was associated with increased HIV-risk behaviour.

The co-occurrence of the SAVA syndemic, depression and anxiety as barriers to antiretroviral therapy adherence among sub-Saharan Africa population groups: A scoping review protocol

Introduction

The scale-up of access to antiretroviral therapy has transformed HIV from an acute, terminal disease to a manageable chronic illness. Yet, sustaining high levels of antiretroviral therapy adherence remain a challenge, especially in the sub-Saharan Africa region which is disproportionately affected by HIV. This protocol proposes a scoping review to explore literature reporting on the antiretroviral therapy adherence levels among people who experience substance abuse and violence (SAVA) syndemics, as well as mood disorders such as anxiety and depression among people living with HIV in sub-Saharan Africa.

Methods and analysis

This proposed scoping review will follow Arksey and O’Malley’s methodological framework for conducting scoping reviews as refined by Levac et al. The review will follow the Joanna Briggs Institute’s manual for conducting scoping reviews. Literature searches will be conducted using six databases: Academic search complete; APA PsycArticles; CINAHL; MEDLINE; SocINDEX and Web of science. Title screening will see the “Participant, Concept, Context” framework applied to identify relevant literature and will not include the appraisal of search results. Data charting will follow an adapted version of Trico and colleagues’ PRISMA-ScR and results will be mapped descriptively and in tabular format. Furthermore, results will be discussed within the syndemics model of health, and summarised as a biosocial conceptual model.

Ethics and dissemination

The study will make use of secondary data that are readily available to the public and will not require ethical approval. We intend to publish our results in a peer-reviewed journal and disseminate our findings at relevant conferences and seminars.

IPV, PrEP, and Medical Mistrust

INTRODUCTION

HIV pre-exposure prophylaxis (PrEP) is an effective HIV prevention method for women experiencing intimate partner violence (IPV). This study aimed to examine (1) relationships between physical, sexual, and psychological IPV and women's PrEP communication with a health care provider and domestic violence advocate; and (2) how IPV-specific medical mistrust modifies the association between IPV and PrEP communication.

METHODS

Data were from 2 studies conducted in Connecticut and Baltimore, MD on adult women experiencing IPV (N = 272). Logistic regressions examined associations between IPV, PrEP communication, and IPV-specific medical mistrust.

RESULTS

The average age was 25.7. The most common identity was non-Hispanic black (37.1%), followed by non-Hispanic white (33.8%), Hispanic (20.6%), and non-Hispanic another racial group (8.5%). Higher severity of psychological IPV was associated with more embarrassment to initiate a PrEP discussion with a health care provider (P = 0.009) or domestic violence advocate (P = 0.026). However, women with more severe psychological IPV were more willing to accept a PrEP recommendation from a health care provider (P = 0.033) or domestic violence advocate (P = 0.044). IPV-specific medical mistrust modified the association between physical IPV and willingness to accept a PrEP recommendation by a domestic violence advocate, such that women with physical IPV were significantly less likely to accept a PrEP recommendation by a domestic violence advocate, but only for women with high IPV-specific medical mistrust (P = 0.021).

CONCLUSIONS

PrEP initiation among women experiencing IPV may be strengthened by addressing and dismantling systems that perpetuate IPV-specific medical mistrust and stigma against IPV survivors.

Use of Self-Figure Drawing as an Assessment Tool for Child Abuse: Differentiating between Sexual, Physical, and Emotional Abuse

Child abuse is a worldwide phenomenon with adverse short- and long-term mental and physical negative consequences, with a huge gap between the prevalence of child abuse and disclosure rates. The study aimed to examine and validate the self-figure drawing as an assessment tool to differentiate between three forms of child abuse, i.e., child sexual abuse (CSA), child physical abuse (CPA), and child emotional abuse (CEA). Following the ethical approval, 1707 Thai children (13–18 years old) from the general population (schools) were asked to complete a self-report anonymous questionnaire consisting of four measures (Demographics, Childhood Trauma Questionnaire (CTQ), The Medical Somatic Dissociation Questionnaire (MSDQ), and The Disclosure of Trauma Questionnaire (DTQ)). After completion, they were asked to draw themselves. There was a significantly positive link between the reluctance to disclose and the experience of abuse, indicating that the more severe the abuse the higher the reluctance to disclose. The findings broaden the knowledge of movement and symbols as representations of inner personal conflictual material. Additionally, it substantiates self-figure drawing as an assessment tool and assists practitioners in early child abuse detection.

'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.

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.

Physical fighting among adolescents in eastern Ethiopia: a cross-sectional study

Background

Physical fights have been a common health problem among adolescents, and approximately a million adolescents’ lives are lost due to violence-related incidents worldwide. There is a lack of information on the burden of adolescents’ physical fights in eastern Ethiopia. Hence, the study aims to estimate the magnitude and assess factors associated with physical attacks and fighting among adolescents in eastern Ethiopia.

Methods

A community-based cross-sectional study was conducted among 2424 adolescents in eastern Ethiopia in 2016. Simple random sampling was used to recruit study participants. Data were collected by trained interviewers using a structured questionnaire developed by the Africa Research, Implementation Science and Education (ARISE) network and adapted from the World Health Organization Global school-based student health survey. Descriptive statistics, binary and multivariable logistic regression were performed. Statistical associations were determined using adjusted odds ratio (AOR) at 95% Confidence Intervals (95% CIs) and P-value < 0.05.

Results

Prevalence of physical attacks and physical fights was 5.8%, and 26.4%, respectively. Adolescents who attended school (AOR 0.4, 95% CI: 0.2–0.9) and who chewed Khat (AOR 0.4, 95% CI: 0.2–0.8) were less likely to experience physical attacks. Male adolescents were two times more likely to engage in physical fights than female adolescents (AOR 2.4, 95% CI: 1.8–3.2). In-school adolescents who attended secondary (AOR 0.4, 95% CI: 0.2–0.7) or tertiary level of education (AOR 0.2, 95% CI: 0.1–0.7) were less likely to participate in physical fighting than those with primary level education. Adolescents who had ever engaged in physical work to earn money for food or drink were 1.9 times more likely to be physically attacked compared to those who had not (AOR 1.9, 95% CI: 1.0–3.5).

Conclusion

Physical attacks and fights were found to be common experiences of adolescents in eastern Ethiopia. Future research and programs should emphasize preventive health programs for reducing violence and promoting school enrolment and retention.

"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.