The Association of Racism and Discrimination in Disparities of Hypertensive Disorders of Pregnancy in the United States: An Analysis of PRAMS Data

BACKGROUND

Hypertensive disorders of pregnancy are a leading cause of maternal mortality. Racial disparities in maternal outcomes such as maternal mortality in the United States (US) are well-documented, but the relationship of racism and/or discrimination with one's risk of developing a hypertension during pregnancy (HDP) is not well-studied.

METHODS

Data from 17 sites that asked questions regarding experiences with racism and/or discrimination during pregnancy via the Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 8 (2016-2020) was used. Logistic regression models were used compare the potential of stress induced HDP from perceived experiences of racism and/or discrimination versus the effect of systemic racism and/or discrimination (in healthcare settings and generally) on racial disparities in HDP diagnosis.

RESULTS

Among 9,907 live births, 18% of participants reported they were diagnosed with hypertension during pregnancy, with non-Hispanic Black individuals having the highest rate (21.8%). Regarding experiences of racism and/or discrimination, 76.4% of participants responded "yes", with all races/ethnicities studied here except non-Hispanic White individuals responding "yes" at rates higher than 89%. Perceived experiences of racism and/or discrimination did not statistically significantly affect one's odds of being diagnosed with HDP (OR = 0.94, CI: 0.74, 1.20). The disparity in odds of having hypertension during pregnancy between Non-Hispanic Black individuals and non-Hispanic White individuals was not statistically significant when perceived experiences of racism and/or discrimination were included in the model.

CONCLUSIONS

Experiences of racism and/or discrimination drive racial disparities in hypertensive disorders in pregnancy.

PUBLIC HEALTH IMPLICATIONS

It is vital to eliminate racist and discriminatory practices and behaviors to reduce maternal morbidity and mortality.

'I am because you are': Community support as a bridge to mental wellbeing for resettled African refugee women living in Rhode Island

African refugee women resettled in the United States are exposed to multiple risk factors for poor mental health. Currently, no comprehensive framework exists on which to guide mental health interventions specific to this population. Through a community-based participatory research partnership, we interviewed N = 15 resettled African refugees living in Rhode Island. Here we (1) describe how meanings of mental health within the African refugee community vary from US understandings of PTSD, depression, and anxiety and (2) generate a framework revealing how mental health among participants results from interactions between social support, African sociocultural norms, and US norms and systems. Multiple barriers and facilitators of mental wellbeing lie at the intersections of these three primary concepts. We recommend that public health and medicine leverage the strength of existing community networks and organisations to address the heavy burden of poor mental health among resettled African refugee women.

Womandla Health: development and rationale of a behavioral intervention to support HIV treatment adherence among postpartum women in South Africa

BACKGROUND

While Option B + has made great strides in eliminating vertical transmission of HIV and improving access to lifelong antiretroviral therapy (ART) for women, the postpartum period remains a risk period for disengagement from HIV care and non-adherence.

METHODS

Longitudinal qualitative data was collected from 30 women living with HIV in Cape Town, South Africa from pregnancy through 1 year postpartum to examine key barriers and facilitators to HIV treatment adherence across this transition. Participants were also asked about their preferences for behavioral intervention content, format, and scope. The intervention development process was guided by Fernandez et al.'s Intervention Mapping process and was informed by the qualitative data, the wider literature on ART adherence, and Transition Theory.

RESULTS

The Womandla Health Intervention is a multicomponent intervention consisting of four individual sessions with a lay health worker and four peer group sessions, which span late pregnancy and early postpartum. These sessions are guided by Transition Theory and utilize motivational interviewing techniques to empower women to ascertain their own individual barriers to HIV care and identify solutions and strategies to overcome these barriers.

CONCLUSIONS

This intervention will be tested in a small scale RCT. If successful, findings will provide an innovative approach to HIV treatment by capitalizing on the transition into motherhood to bolster self-care behaviors, focusing on ART adherence and also women's overall postpartum health and psychosocial needs.

Barriers and facilitators to scaling up access to HIV pre-exposure prophylaxis among key populations: A qualitative study of the incentive-based PrEP Seguro program in Mexico

Introduction

Daily oral pre-exposure prophylaxis (PrEP) is highly safe and effective for HIV prevention, yet barriers to PrEP access and adherence persist among key populations. In Mexico, incentive-based pilot programs have been effective in improving PrEP adherence among male sex workers. Understanding the experiences of providers and program implementers is critical to integrating PrEP adherence programs as part of standard care in Mexico and similar settings.

Methods

We conducted 17 in-depth informational interviews with care providers and staff responsible for administering PrEP to key populations (men who have sex with men, male sex workers, transgender women) in Mexico City. Interviews explored successes and challenges surrounding current PrEP implementation, as well as adaptations that could facilitate national scale-up of PrEP programs in Mexico. Informant transcripts were analyzed using a hybrid inductive-deductive thematic analysis approach utilizing CFIR constructs for the initial codebook while allowing for inductive findings.

Results

Three key themes emerged from informant interviews as important for promoting PrEP programs in Mexico: 1) increasing individual PrEP access, 2) strengthening quality of care, and 3) improving organizational and structural support.

Conclusions

PrEP in Mexico is currently only available in a few clinics with high patient populations, and siloed HIV services, stigma, and a lack of inter-organizational collaboration remain persistent barriers to PrEP uptake. Promoting government collaboration and increasing financial support for community-based organizations is needed to expand PrEP access. Tailored, destigmatizing information about PrEP services needs to be diffused among both staff and patients to strengthen care quality.

Using audience segmentation to identify implementation strategies to improve PrEP uptake among at-risk cisgender women: a mixed-methods study protocol

BACKGROUND

In the USA, 19% of new HIV infections occur among cisgender women (cis women); however, only 10% of eligible cis women have been prescribed pre-exposure prophylaxis (PrEP) for the prevention of HIV infection (an evidence-based intervention). A fundamental challenge for expanding HIV prevention to cis women is ensuring implementation strategies are tailored to the various healthcare settings in which cis women seek care and the heterogeneous providers nested within these settings. This project's specific aims are to (1) explore clinician-level characteristics and organizational climate factors that are related to variability in adoption of PrEP service delivery as an evidence-based intervention for cis women; (2) identify latent audience segments of women's health providers as the related to PrEP acceptability, adoption, and maintenance and analyze demographic correlates of these segments; and (3) identify audience segment-specific implementation strategies to facilitate the adoption of PrEP as an evidence-based intervention among at-risk cis women.

METHODS

Using the i-PARIHS framework, this mixed-methods study examines three domains for guiding audience segmentation to facilitate PrEP implementation for cis women: innovation (degree of fit with existing practices, usability), recipient beliefs and knowledge and context factors (organizational culture, readiness for change), needs to determine appropriate facilitation methods. To achieve aim 1, qualitative interviews will be conducted with PrEP-eligible cis women, women's health providers, and other key stakeholders. Aim 2 will consist of a quantitative survey among 340 women's health providers. Latent class analysis will be used to facilitate audience segmentation. To achieve aim 3, a panel of 5-8 providers for each audience segment will meet and engage in iterative discussions guided by Fernandez's implementation mapping to identify (1) implementation outcomes and performance objectives, determinants, and change objectives and (2) determine and refine of implementation strategies for each audience segment.

DISCUSSION

This exploratory mixed methods study will provide an empirical foundation to inform the development implementations strategies aimed at increasing PrEP delivery to cis women among heterogenous groups of providers.

Maternal perinatal depression and child brain structure at 2-3 years in a South African birth cohort study

Maternal perinatal depression is associated with risk of adverse child developmental outcomes and differences in offspring brain structure. Evidence from low- and middle-income countries is lacking as is an investigation of antenatal, postnatal, and persistent depression in the same sample. In a South African birth cohort, we investigated the effect of antenatal and postpartum maternal depressive symptoms on offspring brain structure at 2-3 years of age. Magnetic resonance imaging was performed, extracting cortical thickness and surface areas in frontal cortex regions of interest and subcortical volumes using FreeSurfer software. Maternal depressive symptoms were measured using the Edinburgh Postpartum Depression Scale and the Beck Depression Inventory II antenatally and at 6-10 weeks, 6 months, 12 months, and 18 months postpartum and analyzed dichotomously and continuously. Linear regressions were used controlling for child age, sex, intracranial volume, maternal education, age, smoking, alcohol use and HIV. 146 children were included with 38 (37%) exposed to depressive symptoms antenatally and 44 (35%) exposed postnatally. Of these, 16 (13%) were exposed to both. Postpartum, but not antenatal, depressive symptoms were associated with smaller amygdala volumes in children (B = -74.73, p = 0.01). Persistent maternal depressive symptoms across pregnancy and postpartum were also independently associated with smaller amygdala volumes (B = -78.61, p = 0.047). Differences in amygdala volumes among children exposed to postnatal as well as persistent maternal depressive symptomatology underscore the importance of identifying women at-risk for depression during the entire perinatal period.

Subcortical brain volumes in young infants exposed to antenatal maternal depression: Findings from a South African birth cohort

BACKGROUND

Several studies have reported enlarged amygdala and smaller hippocampus volumes in children and adolescents exposed to maternal depression. It is unclear whether similar volumetric differences are detectable in the infants' first weeks of life, following exposure in utero. We investigated subcortical volumes in 2-to-6 week old infants exposed to antenatal maternal depression (AMD) from a South African birth cohort.

METHODS

AMD was measured with the Beck Depression Inventory 2nd edition (BDI-II) at 28-32 weeks gestation. T2-weighted structural images were acquired during natural sleep on a 3T Siemens Allegra scanner. Subcortical regions were segmented based on the University of North Carolina neonatal brain atlas. Volumetric estimates were compared between AMD-exposed (BDI-II ⩾ 20) and unexposed (BDI-II < 14) infants, adjusted for age, sex and total intracranial volume using analysis of covariance.

RESULTS

Larger volumes were observed in AMD-exposed (N = 49) compared to unexposed infants (N = 75) for the right amygdala (1.93% difference, p = 0.039) and bilateral caudate nucleus (left: 5.79% difference, p = 0.001; right: 6.09% difference, p < 0.001). A significant AMD-by-sex interaction was found for the hippocampus (left: F(1,118) = 4.80, p = 0.030; right: F(1,118) = 5.16, p = 0.025), reflecting greater volume in AMD-exposed females (left: 5.09% difference, p = 0.001, right: 3.54% difference, p = 0.010), but not males.

CONCLUSIONS

Volumetric differences in subcortical regions can be detected in AMD-exposed infants soon after birth, suggesting structural changes may occur in utero. Female infants might exhibit volumetric changes that are not observed in male infants. The potential mechanisms underlying these early volumetric differences, and their significance for long-term child mental health, require further investigation.

“We Should Be Taught Self-Respect, Self-Confidence and Self-Love”: Youth Perspectives of Adult Influences on Their Sexuality and Relationships Among South African Adolescents Living With HIV

Introduction

Of the 1.75 million adolescents aged 10–19 years living with HIV globally, 84% reside in sub-Saharan Africa. This problem is most acute in South Africa, where there are 720,000 adolescents living with HIV (ALHIV). ALHIV navigate the same challenges as other adolescents—such as puberty and first relationships—as well as challenges specific to their HIV-status—including stigma, disclosure, and concerns about HIV transmission. This dual burden calls for tailored sexual and reproductive health (SRH) programs. Here, we qualitatively explore the reflections of South African ALHIV on SRH education, communication, and discussion provided by adults in schools, clinics, and the home related to their unique SRH needs.

Methods

This paper reports on qualitative data from a mixed-methods study to inform interventions that meet the SRH needs of ALHIV. In-depth interviews (N = 20) were conducted with ALHIV recruited from two clinics in Cape Town, South Africa. Nine males and 11 females aged 16–19 participated in semi-structured in-depth interviews to discuss their sexual health as ALHIV. The interview guide explored 1) perceived SRH needs; 2) healthy living with HIV; 3) future goals; 4) intimate relationships; 5) psychosocial challenges; and 6) preferred interventions. Data were thematically applied to an iteratively-developed codebook and analyzed by the cross-cultural research team using NVivo 12.

Results

These qualitative data reveal the pressing needs among ALHIV for open communication and accurate information about sexuality and HIV, given the risk to themselves and their partners as they enter intimate relationships. Three themes emerged from the data: 1) Intergenerational pressures coming from caregivers, clinicians, and teachers often stigmatize the sexual heath behaviors of ALHIV; 2) When present, open intergenerational communication can provide ALHIV with crucial information, resources, and social support that supports healthy decisions, and 3) ALHIV offer specific ideas about how adults can support their decision-making in the transition to adulthood.

Conclusions

Findings highlight adolescents' recommendations for programs involving open communication, stigma-reduction around sexuality, and support from both peer and adult mentors. This study lays the foundation for strategies to improve intergenerational communication about sexual health to promote positive approaches to sexuality for ALHIV.

Empowerment in pregnancy: ART adherence among women living with HIV in Cape Town, South Africa

RATIONALE

Adherence to antiretroviral therapy (ART) is a global concern among pregnant and postpartum women living with HIV (WLHIV). Research focusing on peripartum WLHIV and how they balance adherence, engaging in HIV care, and other forms of self-care is limited. Women's empowerment theories have been applied to myriad health behaviors to understand patterns, establish mechanisms, and develop interventions; yet empowerment theory as applied to ART is under-researched.

OBJECTIVE

Seeking deeper insight into peripartum health behaviors, we examine these factors using Naila Kabeer's (1999) women's empowerment theory, which denotes resources, agency, and achievements as three primary and interrelated components of empowerment.

METHODS

Data were collected in Gugulethu, South Africa, between March and July 2018. Thirty in-depth interviews were conducted with WLHIV at 32-35 weeks of pregnancy, with topics including experiences related to ART adherence and meanings of empowerment in motherhood. Analyses had two phases: (1) inductive open-coding for emergent themes; and (2) classifying themes into Kabeer's empowerment theory.

RESULTS

Participants expressed that resources play a critical role in adherence, ranging from practical support to motivational support provided by both family and partners. Agency is experienced as a desire to be an independent mother in the often-expected event that partners withdraw support. Participants described achievements as time-oriented goals, ranging from having a baby born without HIV to living a long and productive life.

CONCLUSIONS

These findings suggest that a promising and innovative approach to improving ART adherence across the peripartum transition would focus on understanding resources as an enabling environment, build on existing feelings of agency, and highlight the lifelong goals achievable with high levels of adherence. A better understanding of how women's empowerment evolves over the course of pregnancy and into the postpartum period will support intervention development aimed at improving ART adherence and potentially additional peripartum health behaviors.

"I Found Out I was Pregnant, and I Started Feeling Stressed": A Longitudinal Qualitative Perspective of Mental Health Experiences Among Perinatal Women Living with HIV

Globally, depressive symptoms among pregnant and postpartum (i.e., perinatal) women living with HIV (WLWH) are alarmingly high and associated with poor outcomes such as suboptimal adherence to antiretroviral therapy (ART), and early cessation of exclusive breastfeeding (EBF). Few qualitative studies have described the experience of perinatal depression among WLWH to identify the underlying social-structural determinants of poor mental health and potential strategies to intervene. We conducted a longitudinal qualitative study applying semi-structured interviews with 30 WLWH at three timepoints (28-38 weeks pregnant, 6-weeks postpartum and 5-7 months postpartum) to understand mental health experiences of perinatal WLWH in western Kenya. Financial insecurity emerged as the central theme impacting the mental health of women across time. Financial insecurity was often attributed to the loss of employment, related to pregnancy and the demands of breastfeeding and caring for an infant, as well as a lack of support from male partners. The loss of income and subsequent financial strain contributed to worsening levels of food insecurity and relationship stress and challenged engagement in HIV care. In this way, increased financial strain during the perinatal period negatively impacted the mental health of perinatal WLWH. Our findings suggest support to meet basic needs and remain engaged in HIV care during pregnancy and postpartum could improve perinatal mental health for WLWH in this setting.

Systematic review of research focused on pregnant and postpartum women living with HIV: A relational ethics perspective

Historically, maternal HIV research has focused on prevention of mother-to-child transmission and child outcomes, with little focus on the health outcomes of mothers. Over the course of the HIV epidemic, the approach to including pregnant women in research has shifted. The current landscape lends itself to reviewing the public health ethics of this research. This systematic review aims to identify ethical barriers and considerations for including pregnant and postpartum women living with HIV in treatment adherence and retention research. We completed a systematic literature review following PRISMA guidelines with analysis using a relational ethics perspective. The included studies (n = 7) identified ethical barriers related to (a) women research participants as individuals, (b) partner and family dynamics, (c) community perspectives on research design and conduct, and (d) policy and regulatory implications. These broader contextual factors will yield research responsive to, and respectful of, the needs of pregnant and postpartum women living with HIV. While current regulatory and policy environments may be slow to change, actions can be taken now to foster enabling environments for research. We suggest that a relational approach to public health ethics can best support the needs of pregnant and postpartum women living with HIV; acknowledging this population as systematically disadvantaged and inseparable from their communities will best support the health of this population.

Longitudinal Qualitative Methods in Health Behavior and Nursing Research: Assumptions, Design, Analysis and Lessons Learned

Longitudinal qualitative research (LQR) is an emerging methodology in health behavior and nursing research. Researchers are turning to LQR to understand experiences across time as well as identify facilitators and inhibitors of health/illness behaviors and transitions. Currently, a lack of information exists to guide researchers on LQR techniques and considerations. Our objective was to provide a methodological resource for health behavior and nursing researchers conducting LQR. LQR may be applied to understand any human experience, as well as the sequalae of the experience and is well suited for studying transitions and developmental or behavioral changes. Conducting LQR is resource intensive and requires flexibility and complex analyses. We discuss multiple components of LQR such as design considerations, analysis options, and our lessons learned. Despite complexities, LQR provides the opportunity to understand experiences across time within an individual and among a group resulting in holistic, in-depth understandings beyond a cross-sectional time point.

Perinatal depression among mothers in a South African birth cohort study: Trajectories from pregnancy to 18 months postpartum

BACKGROUND

Perinatal depression affects 21-50% of women in South Africa and poses significant health risks to mothers and children. Trajectories of depressive symptoms change over time and have not been well characterized during the perinatal period in low and middle-income countries.

METHODS

Data from women enrolled in a population-based birth cohort study in Paarl, South Africa with at least 3 depression measures from pregnancy through 18 months postpartum (N = 831) were analyzed. Depressive symptoms were measured continuously using the Edinburgh Postnatal Depression Scale (EPDS). Group-based trajectory models were used to estimate trajectories of depressive symptoms during the perinatal period and multinomial multivariable models to identify predictors of trajectory group membership.

RESULTS

Five distinct trajectory patterns of depressive symptoms were identified: moderate levels of depressive symptoms during pregnancy but minimal postpartum (3.5%), minimal levels during pregnancy and increasing postpartum (3.7%), unstable levels peaking at 12 months postpartum (6.6%), mild levels with slight decrease postpartum (82.9%), and severe levels during pregnancy and postpartum (3.1%). Membership in the chronic severe symptom group was associated with stressful life events, sexual intimate partner violence and tobacco use.

LIMITATIONS

Modeling limitations prevented determining how changes in psychosocial predictors over time may influence depressive symptom trajectories.

CONCLUSIONS

Mild to severe depressive symptoms during pregnancy/postpartum were common among this South African cohort. Interventions to treat women with severe chronic depressive symptoms with co-occurring psychosocial issues are urgently needed.

Maternal health and birth outcomes in a South African birth cohort study

Background

Maternal physical and mental health during pregnancy are key determinants of birth outcomes. There are relatively few prospective data that integrate physical and mental maternal health measures with birth outcomes in low- and middle-income country settings. We aimed to investigate maternal health during pregnancy and the impact on birth outcomes in an African birth cohort study, the Drakenstein Child Health Study.

Methods

Pregnant women attending 2 public health clinics, Mbekweni (serving a predominantly black African population) and TC Newman (predominantly mixed ancestry) in a poor peri-urban area of South Africa were enrolled in their second trimester and followed through childbirth. All births occurred at a single public hospital. Maternal sociodemographic, physical and psychosocial characteristics were comprehensively assessed. Multivariable linear regression models were used to explore associations between maternal health and birth outcomes.

Results

Over 3 years, 1137 women (median age 25.8 years; 21% HIV-infected) gave birth to 1143 live babies. Most pregnancies were uncomplicated but gestational diabetes (1%), anaemia (22%) or pre-eclampsia (2%) occurred in a minority. Most households (87%) had a monthly income of less than USD 350; only 27% of moms were employed and food insecurity was common (37%). Most babies (80%) were born by vaginal delivery at full term; 17% were preterm, predominantly late preterm. Only 74 (7%) of babies required hospitalisation immediately after birth and only 2 babies were HIV-infected. Food insecurity, socioeconomic status, pregnancy-associated hypertension, pre-eclampsia, gestational diabetes and mixed ancestry were associated with lower infant gestational age while maternal BMI at enrolment was associated with higher infant gestational age. Primigravida or alcohol use during pregnancy were negatively associated with infant birth weight and head circumference. Maternal BMI at enrolment was positively associated with birth weight and gestational diabetes was positively associated with birth weight and head circumference for gestational age. Smoking during pregnancy was associated with lower infant birth weight.

Conclusion

Several modifiable risk factors including food insecurity, smoking, and alcohol consumption during pregnancy were identified as associated with negative birth outcomes, all of which are amenable to public health interventions. Interventions to address key exposures influencing birth outcomes are needed to improve maternal and child health in low-middle income country settings.

"You must leave but I didn't want to leave": qualitative evaluation of the integration of ART into postnatal maternal and child health services in Cape Town, South Africa

Postpartum HIV care retention rates are well below retention rates of the general adult population. The Maternal-Child Health Antiretroviral Therapy (MCH-ART) trial tested the benefit of integrating postpartum maternal ART and pediatric care through the end of breastfeeding compared to the standard of care of immediate postpartum referral of mother and infant to separate services. After the trial, twenty-one participants completed in-depth interviews to understand the acceptability of the service integration and the potentially differing "lived" experiences of the women randomized to the two conditions. Key findings include: (1) the MCH-ART integrated service was found to be acceptable, (2) women in the intervention condition expressed more negative feelings around the need to be transferred to general ART services and (3) women in the intervention condition perceived that they had more influence in selecting the clinic to which they would be transferred compared to those in the control group, although there was no actual difference by study design. Future work should more directly evaluate the impact of shared decision-making and long-term relationships with clinic staff on patient engagement and retention in HIV care.

Perpetration of sexual aggression among adolescents in South Africa

INTRODUCTION

In South Africa, one in three men have reported perpetrating rape. Adolescence presents a unique developmental period for primary prevention of violence. However, few studies characterize the epidemiology of sexual violence among adolescents in South Africa.

METHOD

We evaluated rates of sexual violence behaviors using a baseline survey of N = 200 South African adolescents, age 13-15, recruited for participation in an intervention trial. The intervention focused on preventing onset of depression and sexual risk behavior among adolescents. This sample of adolescents were at elevated risk for depression and recruited using house-to-house methods in the community. Sexual perpetration behaviors were assessed using the Sexual Experiences Survey - Short Form Perpetration.

RESULTS

Adolescents most frequently reported the use of coercion, incapacitation, force or threats of force to perpetrate oral sex (15%) followed by sexual touching (14%), anal sex (8%), and vaginal sex at (6%). Perpetration was more common among males compared to females with males perpetrating at a rate of 34.5% vs. 20.5% among females. Attempted perpetration was reported at alarming rates including: vaginal sex (8%), oral sex (8%), and anal sex (5%).

CONCLUSIONS

Primary prevention of sexual violence perpetration, including gender- and developmentally-tailored approaches, are urgently needed for adolescents.

Food Insecurity, Substance Use, and Sexual Transmission Risk Behavior Among People Living with HIV: A Daily Level Analysis

People living with HIV in poverty have limited tangible and mental resources coupled with competing demands for these resources. Competing demands require individuals to make choices that may be beneficial to them in the short term but not in the long term. Past research has shown that food insecurity is related to sexual risk behaviors among people living with HIV. Individuals who are food insecure may sell sex in order to obtain food or lack of food may lead to a depletion of mental resources to negotiate safe sex. Substance use may also create additional constraints on these already limited resources. The current study tested the relation between food insecurity and day-level sexual risk behavior and the possible mediating role that alcohol/substance use may play. Men and women living with HIV were enrolled in a 28-day prospective study between October 2012 and April 2014 in which they completed daily text message surveys regarding their sex behaviors and substance/alcohol use in the context of sex. A total of 796 participants reported sex on 3894 days. On days in which sex occurred, baseline food insecurity was negatively associated with daily condom use. There was also a significant effect of substance use in the context of sex on the rates of change in condom use over time, and this interaction between substance use and time was a partial mediator of the relation between food insecurity and condom use. Gender did not moderate this mediation. Situation-specific alcohol and drug use should be integrated into interventions that target food insecurity and HIV prevention.

The Daily Relationship Between Aspects of Food Insecurity and Medication Adherence Among People Living with HIV with Recent Experiences of Hunger

BACKGROUND

Limited access to resources can significantly impact health behaviors. Previous research on food insecurity and HIV has focused on establishing the relationship between lacking access to nutritious food and antiretroviral (ARV) medication non-adherence in a variety of social contexts.

PURPOSE

This study aims to determine if several aspects of food insecurity co-occur with missed doses of medication on a daily basis among a sample of people living with HIV who have recently experienced hunger.

METHODS

The current study utilized a prospective, observational design to test the daily relationship between food insecurity and medication non-adherence. Participants were followed for 45 days and completed daily assessments of food insecurity and alcohol use via interactive text message surveys and electronic medication adherence monitoring using the Wisepill.

RESULTS

Fifty-nine men and women living with HIV contributed a total of 2,655 days of data. Results showed that severe food insecurity (i.e., hunger), but not less severe food insecurity (i.e., worrying about having food), significantly predicted missed doses of medication on a daily level. Daily alcohol use moderated this relationship in an unexpected way; when individuals were hungry and drank alcohol on a given day, they were less likely to miss a dose of medication.

CONCLUSIONS

Among people living with HIV with recent experiences of hunger, this study demonstrates that there is a daily relationship between hunger and non-adherence to antiretroviral therapy. Future research is needed to test interventions designed to directly address the daily relationship between food insecurity and medication non-adherence.

Perinatal Depression Among HIV-Infected Women in KwaZulu-Natal South Africa: Prenatal Depression Predicts Lower Rates of Exclusive Breastfeeding

Exclusive breastfeeding (EBF) provides infants with optimal nutrition, and together with appropriate antiretroviral therapy has also been shown to decrease mother-to-child transmission of HIV from 45 to less than 1 %. However, rates of EBF are particularly low in South Africa, where rates of HIV are some of the highest in the world. Although perinatal depression has been identified as a potential barrier to EBF, little is known about its impact on EBF among HIV-infected women. A cohort study was conducted as part of a pilot randomized controlled trial (RCT) examining the effect of an Information, Motivation and Behavioral skills-based intervention promoting EBF among South African women living with HIV in their third trimester (28-42 weeks) of pregnancy. At baseline and follow-up, participants were interviewed on depression symptoms (PHQ-9), and breastfeeding intentions and behavior. Multivariate logistic regressions were conducted to determine predictors of EBF at 6-weeks postpartum. A total of 68 women were enrolled and 58 women completed both baseline and follow-up assessments. Most (80.9 %) of the sample reported at least some symptoms of depression prenatally. Rates of depression were lower postpartum (47.1 %). In multivariate models, higher prenatal depression scores significantly predicted lower likelihood of EBF at 6-weeks postpartum after adjusting for demographics, condition, and intentions (AOR = 0.68, p < 0.05). Postpartum depression was not a significant predictor of EBF rates (AOR = 0.99, p = 0.96). These findings demonstrate the negative impact of prenatal depression on breastfeeding behavior. Future interventions focused on depression are warranted to identify those at risk for sub-optimal EBF. Improving maternal psychosocial well-being could be a new frontier to improving infant and young child feeding and reducing pre/postnatal transmission.

The differences between medical trust and mistrust and their respective influences on medication beliefs and ART adherence among African-Americans living with HIV

OBJECTIVE

The purpose of this study was to examine the relationships between medical mistrust and trust and to determine if these measures differentially predict antiretroviral therapy (ART) medication adherence for African-American adults living with HIV.

DESIGN

A total of 458 HIV positive African-Americans completed a cross-sectional survey.

MAIN OUTCOME MEASURES

Self-reported ART adherence was collected using the visual-analog scale. The Beliefs About Medicines Questionnaire was used to assess medication necessity and concern beliefs.

RESULTS

All measures of medical mistrust and trust were significantly negatively correlated, ranging from r = -.339 to -.504. Race-based medical mistrust significantly predicted medication necessity and concern beliefs, whereas general medical mistrust only significantly predicted medication concerns. Both measures of trust significantly predicted medication necessity beliefs and medication concerns. Higher levels of race-based medical mistrust predicted lower medication adherence, whereas, neither trust in own physician nor trust in health care provider significantly predicted medication adherence. However, trust in own physician significantly predicted medication necessity beliefs, which predicted medication adherence.

CONCLUSION

Trust and mistrust are not simply opposites of one another. These findings provide evidence for the complexity of understanding the relationship between health care trust, mistrust and patient-related health beliefs and behaviours.

Alcohol-antiretroviral therapy interactive toxicity beliefs and daily medication adherence and alcohol use among people living with HIV

Alcohol-antiretroviral therapy (ART) interactive toxicity beliefs reflect perceived adverse outcomes of mixing alcohol and ART. Previous research has shown a significant relationship between alcohol-ART interactive toxicity beliefs and ART non-adherence, over and above other correlates of non-adherence such as human immunodeficiency virus (HIV)symptoms and frequency of alcohol use. Most past studies have collected data over extended periods and have not determined if alcohol use and missed medications occur at the day-level among people holding interactive toxicity beliefs. Previous daily analyses, however, have been limited by self-reported adherence and relatively short periods of observation. To address these gaps in the literature, men and women living with HIV in Atlanta, GA, were enrolled in a 45-day observational cohort study. Daily alcohol use was collected using two-way interactive text message surveys and daily adherence was collected via the Wisepill device. Fifty-seven participants completed a measure of alcohol-ART interactive toxicity beliefs and contributed 2565 days of daily data. Participants who endorsed high levels of interactive toxicity beliefs had significantly more days when they missed doses of medication. Alcohol-antiretroviral toxicity beliefs predicted missing doses of medication on days when participants were drinking and on days when they were not drinking. Multilevel multivariate regressions showed that these toxicity beliefs predicted daily missed doses of medication over and above quantity of alcohol consumed, depression and general medication concerns. This study replicates and extends previous literature and indicates the necessity of addressing alcohol-ART toxicity beliefs within adherence interventions.

Optimal Treatment Adherence Counseling Outcomes for People Living with HIV and Limited Health Literacy

Limited health literacy has been shown to contribute to poor adherence to antiretroviral therapy (ART) in people living with HIV/AIDS. Given the mixed results of previous interventions for people with HIV and low health literacy, investigating possible targets for improved adherence is warranted. The present study aims to identify the correlates of optimal and suboptimal outcomes among participants of a recent skills-based medication adherence intervention. This secondary analysis included 188 men and women living with HIV who had low health literacy and who had complete viral load data. Adherence was assessed by unannounced pill count and follow-up viral loads were assessed by blood draw. Results showed that higher levels of health literacy and lower levels of alcohol use were the strongest predictors of achieving HIV viral load optimal outcomes. The interplay between lower health literacy and alcohol use on adherence should be the focus of future research.

Health behavior predictors of medication adherence among low health literacy people living with HIV/AIDS

One particularly vulnerable population for HIV treatment non-adherence is persons with poor health literacy skills. For these individuals, it is important to simplify medication taking as much as possible by integrating medication adherence into other routine health behaviors. This study aims to ascertain the relationship between medication adherence and other health behaviors. Adults living with HIV (N = 422) completed intake measures and 3 months of unannounced pill counts. Endorsement of diet and exercise behaviors at intake predicted higher medication adherence, over and above other known predictors of medication adherence such as HIV symptoms, depression, social support, and stress. These results support integrating strategies for medication management into a constellation of routine health practices.

Reliability and validity of a single-item rating scale to monitor medication adherence for people living with HIV and lower health literacy

BACKGROUND

Monitoring medication adherence in clinical and research settings may be especially challenging for people with lower literacy skills.

OBJECTIVE

The current study examined the measurement properties of a single-item rating scale (SIRS) for assessing medication adherence in a sample of 468 people living with HIV and lower health literacy skills.

METHODS

Participants completed two versions (computerized and telephone interview) of an SIRS as well as unannounced monthly pill counts. We also collected measures of common correlates of adherence and obtained participants' HIV RNA viral load from medical records.

RESULTS

Results indicated that the SIRS is time stable over one month (r = 0.46 to 0.52). There was limited evidence for modality effects between the computerized and phone administered SIRS. Associations with unannounced pill counts demonstrated concurrent and predictive validity of the SIRS, and criterion-related validity by associations with viral load. However, the SIRS also demonstrated inflated adherence estimates relative to unannounced pill counts and these discrepancies were greatest for persons of lower income and who reported alcohol use.

CONCLUSIONS

A simple SIRS to monitor medication adherence may therefore be reliable and valid for use with people challenged by lower literacy skills in both clinical and research settings.

Text message intervention designs to promote adherence to antiretroviral therapy (ART): a meta-analysis of randomized controlled trials

Background

The efficacy of antiretroviral therapy depends on patient adherence to a daily medication regimen, yet many patients fail to adhere at high enough rates to maintain health and reduce the risk of transmitting HIV. Given the explosive global growth of cellular-mobile phone use, text-messaging interventions to promote adherence are especially appropriate. This meta-analysis synthesized available text messaging interventions to promote antiretroviral therapy adherence in people living with HIV.

Methods

We performed Boolean searches of electronic databases, hand searches of recent year conference abstracts and reverse searches. Included studies (1) targeted antiretroviral therapy adherence in a sample of people living with HIV, (2) used a randomized-controlled trial design to examine a text messaging intervention, and (3) reported at least one adherence measurement or clinical outcome.

Results

Eight studies, including 9 interventions, met inclusion criteria. Text-messaging interventions yielded significantly higher adherence than control conditions (OR = 1.39; 95% CI = 1.18, 1.64). Sensitivity analyses of intervention characteristics suggested that studies had larger effects when interventions (1) were sent less frequently than daily, (2) supported bidirectional communication, (3) included personalized message content, and (4) were matched to participants’ antiretroviral therapy dosing schedule. Interventions were also associated with improved viral load and/or CD4+ count (k = 3; OR = 1.56; 95% CI = 1.11, 2.20).

Conclusions

Text-messaging can support antiretroviral therapy adherence. Researchers should consider the adoption of less frequent messaging interventions with content and timing that is individually tailored and designed to evoke a reply from the recipient. Future research is needed in order to determine how best to optimize efficacy.

Behavioural interventions to reduce sexual risk for HIV in heterosexual couples: a meta-analysis

OBJECTIVES

The current study was conducted to synthesise evaluations of couple-based HIV prevention interventions, assess the efficacy of these interventions in reducing sexual risk, and identify moderators of intervention efficacy.

METHODS

A comprehensive literature search identified 29 interventions (22 reports; N=5168 couples) that met the inclusion criteria, including enrolment of both members of a heterosexual couple, measurement of condom use at baseline and follow-up, and sufficient statistical information to calculate effect sizes. Effect sizes were analysed using fixed-effects and random-effects assumptions; factors related to intervention efficacy were identified using metaregression.

RESULTS

Overall, there were significant increases in condom use from baseline to follow-up (d+=0.78, 95% CI 0.48 to 1.09) and significant decreases in partner concurrency (d+=0.37, 95% CI 0.13 to 0.60). Condom use increased to a greater extent when studies were conducted toward the beginning of the epidemic, were located in countries scoring lower on the Human Development Index, enrolled serodiscordant couples, and delivered intervention content in multiple contexts. Couples who had been together longer, reported higher incidence of sexually transmitted infection, were provided voluntary counselling and testing, and provided outcome measures during face-to-face interviews also reported larger increases in condom use.

CONCLUSIONS

Couple-based interventions are efficacious in reducing unprotected sex within the context of romantic relationships. Future research should continue to improve risk reduction for couples.

A pandemic of the poor: social disadvantage and the U.S. HIV epidemic

The U.S. HIV/AIDS epidemic has evolved over the past 30 years and is now concentrated in socially marginalized and disenfranchised communities. The health disparities in this epidemic are striking, with most HIV infections occurring in sexual minorities and communities of color. While widely recognized, the health disparities in HIV and AIDS are not often discussed. In this article, we examine the factors underlying health disparities in the U.S. HIV epidemic. We first discuss the interlocking relationships between biological, social, and behavioral factors that drive HIV/AIDS epidemics. Guided by a well-established conceptual model of health disparities, we then describe the social positions of those most affected by HIV and AIDS, particularly racial and gender groups. Structural and economic conditions-including environmental resources, constraints, access to care, and psychosocial influences-are examined in relation to HIV disease trajectories. Greater attention to contextual factors and comorbidities is needed to reduce the health disparities in HIV/AIDS.

Mixing it Up: Integrating Men and Women Living with HIV/AIDS in Prevention Groups

AIMS

The current study was conducted to examine the impact of mixing genders in HIV prevention intervention groups targeted toward HIV positive men and women.

METHODS

Men (N=310) and women (N=126) participated in a randomized clinical trial testing a behavioral risk reduction/ medication adherence intervention versus a general health control condition administered to small mixed gender groups. Gender composition of groups was examined in relation to participant group attendance and group satisfaction measures through correlations and logistic regression.

RESULTS

Significant regression models were found for men in the risk reduction condition and for women in the general health condition, however, regression models were not significant for women in the risk reduction condition and men in the general health condition.

DISCUSSION

The findings indicate that mixing genders in risk reduction interventions for men and women living with HIV/AIDS has no negative impact on women's group satisfaction and may positively impact men's group satisfaction. This calls into question the assumption that gender sensitive material will always make individuals uncomfortable within mixed gender groups.

IMPLICATIONS FOR PRACTICE AND POLICY

In practice, mixed gender intervention groups can be a helpful option for delivering programs to diverse populations especially when resources are limited within community-based services providers and AIDS service organizations.

CONCLUSION

Although more thorough investigation is needed about the consequences and possible benefits of mixing genders within HIV prevention intervention groups, this study supports the idea that mixing genders may be a viable option, in practice, without sacrificing the integrity of the intervention.

Service priorities and unmet service needs among people living with HIV/AIDS: results from a nationwide interview of HIV/AIDS housing organizations

Housing for people living with HIV/AIDS (PLWHA) has been linked to a number of positive physical and mental health outcomes, in addition to decreased sexual and drug-related risk behavior. The current study identified service priorities for PLWHA, services provided by HIV/AIDS housing agencies, and unmet service needs for PLWHA through a nationwide telephone survey of HIV/AIDS housing agencies in the USA. Housing, alcohol/drug treatment, and mental health services were identified as the three highest priorities for PLWHA and assistance finding employment, dental care, vocational assistance, and mental health services were the top needs not being met. Differences by geographical region were also examined. Findings indicate that while housing affords PLWHA access to services, there are still areas (e.g., mental health services) where gaps in linkages to care exist.

Meta-analysis of single-session behavioral interventions to prevent sexually transmitted infections: implications for bundling prevention packages

Evidence-based, single-session behavioral interventions are urgently needed for preventing the spread of HIV and other sexually transmitted infections (STIs). To estimate the efficacy of single-session, behavioral interventions for STI prevention, we collected data from 29 single-session interventions (20 studies; n = 52 465) with an STI outcome. Infection with an STI was 35% less likely (odds ratio = 0.65; 95% confidence interval = 0.55-0.77) among intervention group participants than among control group participants. Single-session interventions offer considerable benefits in terms of disease prevention and create minimal burden for both the patient and the provider. Brief and effective STI prevention interventions are a valuable tool and can be readily adapted to bolster the benefits of biomedical technologies focusing on the prevention of HIV and other STIs.