Male perspectives on intimate partner violence: A qualitative analysis from South Africa

BACKGROUND

Intimate partner violence (IPV) affects one in four women globally and is more commonly enacted by men than women. Rates of IPV in South Africa exceed the global average. Exploring the background and context regarding why men use violence can help future efforts to prevent IPV.

METHODS

We explored adult men's perspectives of IPV, livelihoods, alcohol use, gender beliefs, and childhood exposure to abuse through a secondary analysis of qualitative interviews that were conducted in South Africa. The setting was a peri-urban township characterized by high unemployment, immigration from rural areas, and low service provision. We utilized thematic qualitative analysis that was guided by the social ecological framework.

RESULTS

Of 30 participants, 20 were residents in the neighborhood, 7 were trained community members, and 3 were program staff. Men reported consumption of alcohol and lack of employment as being triggers for IPV and community violence in general. Multiple participants recounted childhood exposure to abuse. These themes, in addition to culturally prescribed gender norms and constructs of manhood, seemed to influence the use of violence.

CONCLUSION

Interventions aimed at reducing IPV should consider the cultural and social impact on men's use of IPV in low-resource, high-IPV prevalence settings, such as peri-urban South Africa. This work highlights the persistent need for the implementation of effective primary prevention strategies that address contextual and economic factors in an effort to reduce IPV that is primarily utilized by men directed at women.

Redesigning the First Prenatal Visit: A Quality Improvement Initiative

BACKGROUND/PURPOSE

In an era of rising maternal mortality, a thorough first prenatal visit is essential; however, in our clinic we confirmed that many important topics were not being addressed. To rectify this problem, we redesigned the first prenatal visit to improve the coverage of topics, collect social determinants of health, increase patient access, and maintain patient satisfaction.

METHODS

We designed a quality improvement project to improve the first prenatal visit in a faculty obstetrics and gynecology clinic. To assess effectiveness, data before and after the implementation were compared. The intervention divided the first prenatal visit into two patient encounters: a nurse-led telemedicine visit and an in-person visit with an obstetric clinician.

RESULTS

The median percentage of topics covered in the first prenatal visit increased from 70.0% to 95.6%, and improvements were observed for all key themes ( p < .001). Social determinants of health was routinely collected postintervention (98.8%). A reduction in no-shows (9.9%-4.2%) improved patient access for all patients. Patient satisfaction for the first prenatal visit remained unchanged ( p = .370).

CONCLUSIONS

Significant improvements in addressing important topics at the first prenatal visit are achievable by separating one prenatal visit into two visits while increasing patient access and maintaining high patient satisfaction.

Characterizing informational needs and information seeking behavior of patients with breast cancer

BACKGROUND

Appropriate information may facilitate adjustment to cancer diagnoses. Our study aims to characterize informational satisfaction in breast cancer patients and assess resources used by patients to gain information.

METHODS

Newly diagnosed Stage 0-III breast cancer patients seen at an academic medical center between May and September 2020 received questionnaires assessing information satisfaction. Patients indicated resources used to obtain information along with satisfaction with information received in various topics. A subset of questionnaire respondents completed semi-structured interviews.

RESULTS

Fifty-two (35 ​%) patients completed the questionnaire. Patients received information from physicians (96 ​%), the internet (81 ​%), nurses (79 ​%), and fellow breast cancer patients (54 ​%). Interview participants preferred receiving information from providers when making medical decisions but found patient forums and social media to be important adjuncts for receiving information.

CONCLUSION

Patients are satisfied with information received about diagnosis and treatment, but finances, sexual health, and fertility are less frequently discussed.

Information transparency with immediate release: Oncology clinician and patient perceptions

INTRODUCTION

As part of the 21st Century Cures Act (April 2021), electronic health information (EHI) must be immediately released to patients. In this study, we sought to evaluate clinician and patient perceptions regarding this immediate release.

METHODS

After surveying 33 clinicians and 30 patients, semi-structured interviews were conducted with a subset of the initial sample, comprising 8 clinicians and 12 patients. Open-ended questions explored clinicians' and patients' perceptions of immediate release of EHI and how they adjusted to this change.

RESULTS

Ten themes were identified: Interpreting Results, Strategies for Patient Interaction, Patient Experiences, Communication Strategies, Provider Limitations, Provider Experiences, Health Information Interfaces, Barriers to Patient Understanding, Types of Results, and Changes due to Immediate Release. Interviews demonstrated differences in perceived patient distress and comprehension, emphasizing the impersonal nature of electronic release and necessity for therapeutic clinician-patient communication.

CONCLUSIONS

Clinicians and patients have unique insights on the role of immediate release. Understanding these perspectives will help improve communication and develop patient-centered tools (glossaries, summary pages, additional resources) to aid patient understanding of complex medical information.

Money, chores and emotional support: Kenyan and Zambian fathers' perceptions of male partner involvement in maternal and infant health within the context of HIV

In sub-Saharan Africa, involving male partners in the prevention of mother-to-child transmission of HIV improves maternal and infant outcomes. Male involvement is typically conceptualised as male partners attending antenatal care, which is difficult for many men. Little is known about how men view their involvement in family health within the context of HIV, particularly outside of clinic attendance. Through interviews with 35 male partners of pregnant or postpartum women living with HIV in Kenya and Zambia, this study elicited perceptions of male involvement in maternal and infant health in families affected by HIV. Men supported the importance of clinic attendance but reported conflicts with the need to work and fulfil their role as the family's financial provider. Providing money for necessities was deemed more critical for their family's health than clinic attendance. Men's involvement was conveyed through various other supportive actions, including helping with household chores and providing emotional support (showing love and reducing women's stress). Future strategies to promote male partner involvement in the prevention of mother-to-child transmission of HIV and maternal and child health should build upon the actions men view as most meaningful to promote their family's health within their real-world life circumstances and cultural context, particularly their role as financial providers.

Are Diagnostic Delays Associated with Distress in Breast Cancer Patients?

Introduction

Receiving a new breast cancer diagnosis can cause anxiety and distress, which can lead to psychologic morbidity, decreased treatment adherence, and worse clinical outcomes. Understanding sources of distress is crucial in providing comprehensive care. This study aims to evaluate the relationship between delays in breast cancer diagnosis and patient-reported distress. Secondary outcomes include assessing patient characteristics associated with delay.

Methods

Newly diagnosed breast cancer patients who completed a distress screening tool at their initial evaluation at an academic institution between 2014 and 2019 were retrospectively evaluated. The tool captured distress levels in the emotional, social, health, and practical domains with scores of "high distress" defined by current clinical practice guidelines. Delay from mammogram to biopsy, whether diagnostic or screening mammogram, was defined as >30 days.

Result

745 newly diagnosed breast cancer patients met inclusion criteria. Median time from abnormal mammogram to core biopsy was 12 days, and 11% of patients experienced a delay in diagnosis. The non-delayed group had higher emotional (p = 0.04) and health (p = 0.03) distress than the delayed group. No statistically significant differences in social distress were found between groups. Additionally, patients with higher practical distress had longer time interval between mammogram and surgical intervention compared to those with lower practical distress. Older age, diagnoses of invasive lobular carcinoma or ductal carcinoma in situ, and clinical anatomic stages 0-I were associated with diagnostic delay.

Conclusion

Patients with higher emotional or health-related distress were more likely to have timely diagnoses of breast cancer, suggesting that patients with higher distress may seek healthcare interventions more promptly. Improved understanding of sources of distress will permit early intervention regarding the devastating impact of breast cancer diagnosis.

The Effect of Hormonal Contraception Use on Ovarian Reserve Markers and the Uptake of Assisted Reproductive Technology in Individuals Seeking an Infertility Evaluation

Background and objective The effects of hormonal contraception (HC) use on ovarian reserve (OR) markers in individuals seeking an infertility evaluation and the success of assisted reproductive technology (ART) warrant further investigation. Therefore, the aim of this study was to determine if women seeking an evaluation for unexplained infertility who used long-term (≥2 years) HC have lower ovarian reserve (OR) markers and higher uptake of ART compared to short-term (<2 years) or never HC users. Methods We performed a cross-sectional patient survey involving a retrospective medical chart review of patients seeking an evaluation for unexplained infertility at the University of Colorado Advanced Reproductive Medicine (CU ARM) clinic. Results Most participants (87%; 107/123) reported a history of HC use with 98 (79.7%) reporting long-term continuous use for two or more years. Median OR markers were similar between long-term and short-term/never HC users [anti-Müllerian hormone (AMH): 2.4 vs. 3.2, p=0.20; antral follicle count (AFC): 18 vs. 26, p=0.10; follicle-stimulating hormone (FSH): 7.6 vs. 6.3, p=0.26] and remained so after adjusting for age and diagnosis of polycystic ovarian syndrome (PCOS) or primary ovarian insufficiency (POI) in linear regression models. However, among HC users aged less than 30 years (n=9), those who had discontinued HC between two and three years prior to the assessment of their OR markers had a 6.20 ng/mL increase in AMH level compared to those who had discontinued HC less than two years prior to the assessment (p=0.02). Additionally, there was a marginally increased use of ART overall among long-term HC users compared to short-term/never HC users (64.3% vs. 44.0%, p=0.06), specifically in the use of in vitro fertilization (IVF) (58.7% vs. 18.2%, p=0.01). Among long-term HC users, ovulation induction was less likely to result in live birth compared to short-term/never HC users (8.9% vs. 62.5%, p<0.001); however, after adjusting for age, PCOS, POI, and type of ART used, there was no difference in the odds of live birth after ART between long-term HC users and short-term/never users. Conclusion While long-term HC users report increased use of ART, in particular IVF, the overall conception rates and live birth outcomes among ART users do not appear to be significantly affected by a history of long-term HC use.

Teacher and caregiver perceptions of family engagement in teacher-led task-shifted child mental health care in a low-and-middle-income country

The mental health needs of children in low-and-middle income countries (LMICs) often go unmet due to a lack of qualified mental health professionals. Task-shifting the provision of mental health services to teachers may facilitate access to care. Family engagement in task-shifting may support mental health outcomes but is understudied in this context. The current study explored teacher and caregiver perceptions of family engagement within a teacher-led, task-shifted mental health intervention in an LMIC. Primary school teachers from five schools in Darjeeling, India delivered evidence-based, indicated mental health care to children with mental health needs throughout the school day. We conducted semi-structured interviews (SSIs) with teachers (n=17) and caregivers (n=21). SSIs were coded for themes related to family engagement. Teachers and caregivers were compared based on perceived levels of engagement. Participants reported three patterns of engagement: families who fully engaged; families who felt positively about teachers but displayed little engagement; and families with limited engagement. Barriers included logistical challenges and misconceptions about the programme. Many teachers implicated family engagement as a facilitator of the programme, suggesting that family involvement may support intervention outcomes. Future work could involve the development of an intervention component to better facilitate engagement in this context.Trial registration: Clinical Trials Registry India identifier: CTRI/2018/01/011471.

No One-Size-Fits-All: Sexual Health Education Preferences in Patients with Breast Cancer

Background

Using explanatory mixed methods, we characterize the education that patients with breast cancer received about potential sexual health effects of treatment and explore preferences in format, content, and timing of education.

Patients and Methods

Adult patients with stage 0–IV breast cancer seen at an academic breast center during December 2020 were emailed questionnaires assessing sexual health symptoms experienced during treatment. Patients interested in further study involvement were invited to participate in semistructured interviews. These interviews explored sexual health education provided by the oncology team and patient preferences in content, format, and timing of education delivery.

Results

Eighty-seven (32%) patients completed the questionnaire. Most patients reported decreased sexual desire (69%), vaginal dryness (63%), and less energy for sexual activity (62%) during/after treatment. Sixteen patients participated in interviews. Few women reported receiving information about potential sexual effects of breast cancer treatment; patients who did reported a focus on menopausal symptoms or fertility rather than sexual function. Regarding preferences in format, patients were in favor of multiple options being offered rather than a one-size-fits-all approach, with particular emphasis on in-person options and support groups. Patients desired education early and often throughout breast cancer treatment, not only about sexual side effects but also on mitigation strategies, sexual function, dating and partner intimacy, and body image changes.

Conclusion

Few patients received information about the sexual health effects of breast cancer treatment, though many experienced symptoms. Potential adverse effects should be discussed early and addressed often throughout treatment, with attention to strategies to prevent and alleviate symptoms and improve overall sexual health.

Tamoxifen for the Treatment of Etonogestrel Implant-Associated Bleeding in an Adolescent Gynecology Practice

OBJECTIVE

To describe clinical outcomes in a cohort of adolescent female patients using tamoxifen for the treatment of bothersome etonogestrel (ENG) implant-associated bleeding.

DESIGN

Retrospective chart review SETTING: A tertiary children's hospital PARTICIPANTS: Adolescent female patients ages 12-21 seen between August 2016 and August 2019 with an ENG implant in place who received a tamoxifen prescription for the indication of implant-associated bleeding.

INTERVENTIONS

None MAIN OUTCOME MEASURES: Main outcome measures were implant continuation rates, average time to implant discontinuation after tamoxifen prescription, reasons for implant removal, number of doses and timing of tamoxifen use, bleeding patterns, and adverse effects.

RESULTS

A total of 67 patients met the inclusion criteria. The mean age of patients was 16.7 years old. Of the patients with available follow-up data, 49 out of 60 (81.7%) were still using the implant at 12 months, 29 out of 53 (54.7%) at 24 months, and 9 out of 40 (22.5%) at 36 months. The average time from tamoxifen prescription to implant removal was 12.1 months. Bothersome bleeding was the primary reason for ENG implant discontinuation (68.6%). No side effects from tamoxifen use were reported.

CONCLUSION

Tamoxifen was well-tolerated among this cohort of patients and can be considered a treatment option to manage bothersome implant bleeding in adolescents.

Virtual Prenatal and Postpartum Care Acceptability Among Maternity Care Providers

Introduction

The Covid-19 pandemic and statewide stay-at-home orders abruptly impacted clinic operations necessitating the incorporation of telehealth. Uptake of telehealth is multifaceted. Clinician acceptance is critical for success. The aim of this study is to understand maternity care providers’ acceptance of and barriers to providing virtual maternity care.

Methods

Providers completed a baseline and 3-month follow up survey incorporating the validated implementation outcome measures, feasibility of intervention measure (FIM), intervention appropriateness measure (IAM), and acceptability of intervention measure (AIM).Statistical analyses evaluated differences between groups in this small convenience sample to understand trends in perceptions and barriers to telehealth. While not intended to be a qualitative study, a code tree was used to evaluate open-ended responses.

Results

Baseline response rate 50.4% (n = 56). Follow-up retention/response-rate 68% (n = 38). Most reported no prior telehealth experience. 94% agreed with the FIM, decreasing to 92% at follow-up. 80% (prenatal) and 84% (postpartum) agreed with the IAM. Agreement with the AIM increased to 83%.Differences in the FIM and AIM found by division (p < 0.01) and years in practice (p < 0.01). Identified barriers included patient lack of essential tools, inadequate clinic support, and patients prefer in person visits. Themes that emerged included barriers, needs, and areas of success.

Discussion

Telehealth was found to be feasible, appropriate, and acceptable across provider types and divisions. Improving patient/provider access to quality equipment is imperative. Future research must address how and when to incorporate telehealth.

Tenofovir Diphosphate in Dried Blood Spots in Pregnant and Postpartum Women With HIV in Kenya: A Novel Approach to Measuring Peripartum Adherence

BACKGROUND

Adherence to antiretroviral therapy (ART) among pregnant and postpartum women with HIV (PWLWH) is critical to promote maternal health and prevent HIV transmission. Tenofovir diphosphate (TFV-DP) in dried blood spots (DBS) is an objective assessment of cumulative ART adherence that has not been fully assessed in PWLWH.

SETTING

Southwestern Kenya.

METHODS

PWLWH receiving tenofovir disoproxil fumarate-based ART from 24 health facilities provided DBS samples at 3 time points [pregnancy/early postpartum (PP), 6 months PP, and 9-12 months PP]. Thresholds for daily adherence were defined as TFV-DP in DBS ≥650 fmol/punch in pregnancy and ≥950 PP. Descriptive analysis is presented. Cluster adjusted χ2 and t-tests were used to test for association with clinical and demographic factors.

RESULTS

A total of 419 DBS samples were collected from 150 PWLWH. Median TFV-DP in DBS was lowest, 552 fmol/punch [interquartile range (IQR), 395-759] in pregnancy and declined over time [914 (IQR, 644-1176) fmol/punch; early PP; 838 (IQR, 613-1063) fmol/punch 6 months PP; and 785 (IQR, 510-1009) fmol/punch 9-12 months; P < 0.001]. Only 42% of samples in pregnancy and 38.5% of samples in PP met thresholds for daily adherence. Clinical or demographic factors were not associated with suboptimal adherence levels.

CONCLUSION

Cumulative ART exposure in PWLWH, quantified by TFV-DP in DBS, demonstrated a stepwise decrease (ie, adherence) PP. Most women demonstrated less than daily adherence throughout the peripartum period. Use of TFV-DP in DBS as a measure of cumulative ART adherence could help optimize health outcomes in PWLWH and their infants.

A Systematic Review of Behavioral Couples-Based Interventions Targeting Prevention of Mother-to-Child Transmission in Low- and Middle-Income Countries

There is increasing focus in HIV prevention and treatment on couples-based approaches. No systematic review has synthesized prospective behavioral couples-based HIV trials targeting prevention of mother-to-child transmission (PMTCT) outcomes in low- and middle-income countries (LMICs). We systematically reviewed published abstracts and articles reporting prospective comparative evaluations of behavioral couples-based HIV interventions delivered during pregnancy to both members of a self-identified heterosexual couple in LMICs following PRISMA. Citations, abstracts, and full texts were double screened for eligibility. References meeting eligibility criteria underwent double data abstraction, quality appraisal, and qualitative synthesis. We identified 295 unique publications. Of these, 5 randomized trials were deemed eligible and synthesized. Studies were conducted in 3 different African countries using three overarching intervention approaches: home-based; group workshops; and faith-based. Studies included various PMTCT outcome measures. We found evidence that behavioral couples-based approaches around the time of pregnancy can positively affect HIV testing among pregnant women and their male partners, infant HIV prophylaxis use, and HIV-free infant survival. The effects on other PMTCT outcomes were not well supported. There was a low to moderate risk of bias among the included studies. Few couples-based PMTCT interventions have been tested in LMICs. Of the interventions we located, workshops/group education and home-based couple counseling and testing were most commonly used to promote PMTCT. Research is needed on the role of relationship dynamics within such interventions and whether couples-based approaches during pregnancy can extend to health outcomes across the PMTCT continuum of care.

Teacher, caregiver, and student acceptability of teachers delivering task-shifted mental health care to students in Darjeeling, India: a mixed methods pilot study

Background

The acceptability of teachers delivering task-shifted mental health care to their school-aged students is understudied. Here, we evaluate teachers', students', and caregivers' acceptability of Tealeaf (Teachers Leading the Frontlines), an alternative system of care in which teachers are trained and supervised to deliver transdiagnostic, non-manualized task-shifted care to their students.

Methods

In a 2019 single-arm, mixed methods, pragmatic acceptability pilot study in Darjeeling, India, 13 teachers delivered task-shifted child mental health care to 26 students in need. Teachers delivered care through using a transdiagnostic, non-manualized therapy modality, "education as mental health therapy" (Ed-MH). Measured with validated scales, teachers' and students' acceptability were compared after teacher training (PRE) and at the end of intervention (POST) using paired t tests. Teachers (n = 7), students (n = 7), and caregivers (n = 7) completed semi-structured interviews POST.

Results

Teachers' quantitative measures indicated moderate acceptability PRE and POST and did not change PRE to POST. Children's measures showed acceptability PRE and POST but decreased PRE to POST. Teachers and caregivers universally expressed acceptability in interviews. Facilitators of acceptability included impact, trust of teachers, and teachers' ability to make adaptations. Conditions required for acceptability included supervision and teachers emphasizing academics benefits over mental health benefits to caregivers. Barriers to acceptability included a lack of teacher time and stigma. Interviewed students universally were unaware of receiving care; teachers intentionally avoided singling them out.

Conclusion

Teachers, caregivers, and children found teacher delivering task-shifted care acceptable, a key factor in care adoption and sustainability, though interviewed children were unaware of receiving care.Trial registration The trial was registered on January 01, 2018 with Clinical Trials Registry-India (CTRI), Reg. No. CTRI/2018/01/011471, Ref. No. REF/2017/11/015895. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27.

Supplementary Information

The online version contains supplementary material available at 10.1007/s44192-022-00024-z.

Effects of behavioural interventions on postpartum retention and adherence among women with HIV on lifelong ART: the results of a cluster randomized trial in Kenya (the MOTIVATE trial)

INTRODUCTION

Retention in HIV care and adherence to antiretroviral therapy (ART) during pregnancy and postpartum for women living with HIV (WLWH) are necessary to optimize health outcomes for women and infants. The objective of this study was to evaluate the impact of two evidenced-based behavioural interventions on postpartum adherence and retention in WLWH in Kenya.

METHODS

The Mother-Infant Visit Adherence and Treatment Engagement (MOTIVATE) study was a cluster-randomized trial enrolling pregnant WLWH from December 2015 to August 2017. Twenty-four health facilities in southwestern Kenya were randomized to: (1) standard care (control), (2) text-messaging, (3) community-based mentor mothers (cMM) or (4) text-messaging and cMM. Primary outcomes included retention in care and ART adherence at 12 months postpartum. Analyses utilized generalized estimating equations and competing risks regression. Per-protocol analyses examined differences in postpartum retention for women with high versus low levels of exposure to the interventions.

RESULTS

We enrolled 1331 pregnant WLWH (mean age 28 years). At 12 months postpartum, 1140 (85.6%) women were retained in care, 96 women (7.2%) were lost-to-follow-up (LTFU) and 95 (7.1%) were discontinued from the study. In intention-to-treat analyses, the relative risk of being retained at 12-months postpartum was not significantly higher in the intervention arms versus the control arm. In time-to-event analysis, the cMM and text arm had significantly lower rates of LTFU (hazard ratio 0.44, p = 0.019). In per-protocol analysis, the relative risk of 12-month postpartum retention was 24-29% higher for women receiving at least 80% of the expected intervention compared to the control arm; text message only risk ratio (RR) 1.24 (95% confidence interval [CI] 1.16-1.32, p<0.001), cMM only RR 1.29 (95% CI 1.21-1.37, p<0.001) and cMM plus text RR 1.29 (1.21-1.37, p<0.001). Women LTFU were younger (p<0.001), less likely to be married (p<0.001) and more likely to be newly diagnosed with HIV during pregnancy (p<0.001). Self-reported ART adherence did not vary by study arm.

CONCLUSIONS

Behavioural interventions using peer support and text messages did not appear to improve 12-month postpartum retention and adherence in intention-to-treat analyses. Higher levels of exposure to the interventions may be necessary to achieve the desired effects.

Exploring Mental Health and Academic Outcomes of Children Receiving Non-manualized, Transdiagnostic, Task-Shifted Mental Health Care From Their Teachers in a Low-and-Middle Income Country

A majority of children worldwide who face mental health difficulties, especially in low-and-middle income countries, remain undiagnosed and untreated. This deficit roots in part from a lack of trained professionals qualified to provide care. Task-shifting the provision of treatment to teachers, individuals with consistent access to children, can reduce the care gap. The current study investigated whether the implementation of a pilot trial of Tealeaf-Mansik Swastha (Teachers Leading the Frontlines-Mental Health; "Tealeaf") was associated with improvements in child mental health and academic outcomes. Tealeaf is a transdiagnostic, non-manualized, task-shifting intervention in which teachers identify students in need of mental health care and then provide task-shifted care for them using an emerging, novel therapy modality, "education as mental health therapy" (Ed-MH). Pre-post standardized quantitative measures focused on child mental health status and academics. The measures were completed by multiple raters and compared to determine whether changes occurred. Results indicated that primary teacher raters observed significant improvements in child mental health symptoms overall, while secondary teacher raters and caregivers noted improvement for certain diagnostic categories. Caregivers observed on average a decreased impact of their children's mental health symptoms on their children's lives. Academically, math scores significantly improved while reading trended toward significance. Preliminary evidence overall supports the viability of Tealeaf and Ed-MH for positively impacting child mental health and academics. Future directions include the implementation of a formalized, randomized-controlled trial to strengthen preliminary outcomes.

Patient Perceptions of Changes in Breast Cancer Care and Well-Being During COVID-19: A Mixed Methods Study

Background

Widespread healthcare restructuring due to the COVID-19 pandemic led to modifications in the timing and delivery of care for breast cancer patients. Our study explores patient concerns relating to COVID-19, breast cancer, and changes to breast cancer care.

Patients and Methods

Breast cancer patients who presented for surgical consultation at an academic, multidisciplinary clinic completed the electronically distributed validated COVID-19 Impact and Healthcare Related Quality of Life questionnaire between August 2020 and February 2021. This questionnaire uses Likert score responses to assess COVID-specific concerns within domains, including distress and financial hardship. Scale scores were determined by averaging items within each domain, and scores > 2 indicated greater disruption. Semistructured interviews were conducted with patients who indicated interest in participating in the questionnaire.

Results

Of 381 patients recruited, 133 patients completed the questionnaire and 20 patients completed interviews. Sixty-three percent of survey participants reported attending a telemedicine appointment for their cancer care, and the majority (67%) were satisfied with their experience. Half of the participants (50%) reported fear about how the COVID-19 pandemic will impact their cancer care or recovery, and 66% reported anxiety about contracting COVID-19. Twenty-two percent of participants reported decreased income due to COVID-19. Patient interviews revealed tangible changes to care and provided in-depth information on the advantages and disadvantages of telehealth.

Conclusions

Breast cancer patients report anxiety about COVID-19 infection and potential care modifications. Our study identifies impacts on patients’ care and quality of life. Further investigation will inform interventions to improve psychosocial outcomes for patients and the telehealth experience.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-021-11209-1.

Experiences, perceptions and potential impact of community-based mentor mothers supporting pregnant and postpartum women with HIV in Kenya: a mixed-methods study

Introduction

Community‐based mentor mothers (cMMs) are women living with HIV who provide peer support to pregnant/postpartum women living with HIV (PWLWH) to enhance antiretroviral therapy (ART) adherence, retention in care and prevent perinatal transmission of HIV. The goal of this study was to explore the experiences, perceptions, mechanisms and health impact of cMMs on PWLWH in Kenya from the perspective of cMMs.

Methods

We conducted a prospective mixed‐methods study in southwestern Kenya in 2015–2018. In the qualitative phase, we completed in‐depth interviews with cMMs to explore their perceptions and experiences in supporting PWLWH. Transcripts were broad‐coded according to identified themes, then fine‐coded using an inductive approach. In the quantitative phase, we analysed medical record data from PWLWH who were randomized in the cMM intervention to examine the impact of cMM visits on optimal prevention of mother‐to‐child transmission (PMTCT). We used cluster‐adjusted generalized estimating equation models to examine relationships with a composite outcome (facility delivery, infant HIV testing, ART adherence and undetectable viral load at 6 weeks postpartum). Finally, qualitative and quantitative results were integrated.

Results

Convergence of findings from cMM interviews (n = 24) and PWLWH medical data (n = 589) revealed: (1) The cMM intervention was utilized and perceived as acceptable. PWLWH received, on average, 6.2 of 8 intended home visits through 6 weeks postpartum. (2) The cMMs reported serving as role models and confidantes, supporting PWLWH's acceptance of their HIV status, providing assurances about PMTCT and assisting with male partner disclosure and communication. cMMs also described benefits for themselves, including empowerment and increased income. (3) The cMM visits supported PWLWH's completion of PMTCT steps. Having ≥4 cMM home visits up to 6 weeks postpartum, as compared to <4 visits, was associated with higher likelihood of an optimal PMTCT composite outcome (adjusted relative risk 1.42, p = 0.044).

Conclusions

We found that peer support from cMMs during pregnancy through 6 weeks postpartum was associated with improved uptake of critical PMTCT services and health behaviours and was perceived as beneficial for cMMs themselves. CMM support of PWLWH may be valuable for other low‐resource settings to improve engagement with lifelong ART and HIV services among PWLWH.

Designing a couple-based relationship strengthening and health enhancing intervention for pregnant women living with HIV and their male partners in Zambia: Interview findings from the target community

INTRODUCTION

Interpersonal support can promote positive outcomes among people living with HIV. In order to develop an acceptable psychoeducational couples-based intervention aimed at strengthening the relationship context and improving HIV outcomes before and after pregnancy, we conducted qualitative interviews with pregnant women living with HIV and their male partners.

METHODS

We interviewed a convenience clinic-based sample of pregnant women living with HIV (n = 30) and male partners (n = 18) in Lusaka, Zambia. Interviews included pile sorting relationship topics in order of perceived priority. Interviews also focused on family health concerns. Interviews were audio-recorded, translated, transcribed, and thematically analyzed. Pile sorting data was analyzed using descriptive statistics.

RESULTS

All female participants were living with HIV; 61% of the male partners interviewed were additionally living with HIV. The most prioritized relationship topic among both genders was communication between couples. Honesty and respect were important relationship topics but prioritized differently based on gender. Female participants considered emotional and instrumental support from male partners critical for their physical and mental health; men did not prioritize support. Intimate partner violence was discussed often by both genders. Family health priorities included good nutrition during pregnancy, preventing infant HIV infection, safe infant feeding, sexual health, and men's alcohol use.

CONCLUSIONS

A major contribution of this study is a better understanding of the dyad-level factors pregnant women living with HIV and their male partners perceive to be the most important for a healthy, well-functioning relationship. This study additionally identified gaps in antenatal health education and the specific family health issues most prioritized by pregnant women living with HIV and their male partners. The findings of this study will inform the development of an acceptable couples-based intervention with greater likelihood of efficacy in strengthening the relationship context and promoting family health during and after pregnancies that are affected by HIV.

Men's perceptions of sexual and reproductive health education within the context of pregnancy and HIV in Zambia: a descriptive qualitative analysis

BACKGROUND

Although health care providers are beginning to focus on men's roles as fathers and husbands, there is limited understanding of how men view their ability to promote sexual and reproductive health in families affected by HIV and their experiences with receiving education through antenatal care. This paper aims to explore men's perceptions of the education they need regarding sexual and reproductive health within the family in the context of HIV.

METHODS

We interviewed a convenience sample of 18 male partners of pregnant women living with HIV in Lusaka, Zambia. Atlas.ti was used to facilitate data management and content analysis.

RESULTS

Men reported being the primary decision-makers regarding sexual and reproductive issues in the family; however, they admitted far-reaching unmet needs in terms of information on sexual and reproductive health in the context of HIV. Most men felt that antenatal care was not a conducive setting to fully educate men on sexual and reproductive health because it is a woman's space where their health concerns were generally neglected. There was a strong desire for more education that was specific to men's sexual and reproductive health, especially because all the couples were affected by HIV. Men especially requested education on sexual preparedness, safe sex, the use of condoms in sero-concordant and sero-discordant relationships and general health information. Although men stated they were the main decision-makers regarding sexual and reproductive issues such as pregnancy, most men were not confident in their ability to promote sexual and reproductive health in the family because of limited knowledge in this area.

CONCLUSION

There is need to change the environment and messaging of antenatal care, as well as offer relevant education opportunities outside health facility settings to empower men with essential information for meaningful involvement in sexual and reproductive health in the context of HIV.

Choosing Between Mastectomy and Breast-Conserving Therapy: Is Patient Distress an Influencing Factor?

BACKGROUND

Breast-conserving therapy (BCT) offers oncologic outcomes similar to those of mastectomy, yet many patients, when provided the option, choose mastectomy. This study aimed to evaluate the relationship between patient-reported distress and surgical decisions and to determine factors predictive of choosing BCT versus mastectomy.

METHODS

Patients with newly diagnosed breast cancer deemed candidates for BCT who completed a distress screen at their initial visit to an academic institution between 2016 and 2019 were retrospectively reviewed. This screening tool captures distress in emotional, social, health, and practical domains on a scale of 0 to 10. The distress scores were compared against surgical decisions using nonparametric Wilcoxon rank-sum tests. Patient factors associated with surgical choice were analyzed using chi-square, Fisher's exact, and Student's t tests. A two-sided p value lower than 0.05 was considered significant.

RESULTS

Of 506 patients deemed eligible for BCT, 430 (85%) chose BCT and 76 (15%) pursued mastectomy. The distress levels did not differ significantly between the surgical options. The patients who underwent mastectomy were on the average younger (50.7 vs 60.4 years; p < 0.0001), presented with palpable masses (p < 0.0001), had stage 0, 2, or 3 versus stage 1 disease (p < 0.0001), sought consultation for second opinions (19.7% vs 8.6%; p = 0.0032), received neoadjuvant chemotherapy (31.6% vs 16.3%; p = 0.0016), or had deleterious gene mutations (21.1% vs 5.1%; p < 0.0001).

CONCLUSIONS

Distress was not associated with the pursuit of surgical treatment. Rather, younger age, search for a second opinion, and a palpable mass present at presentation were associated with more aggressive surgical decisions. Understanding factors that influence surgical decision-making is critical in guiding informed decisions that reflect patient values.

Teacher Nomination of School-aged Children for Mental Health Services in a Low and Middle Income Country

Background: Knowledgeable in child development, primary school teachers in low- and middle-income countries (LMICs) have the potential to identify their students needing mental health care. Objective: We evaluated whether teachers in Darjeeling, India can accurately nominate school-aged children for mental health services after training and aided by a novel tool. Methods: In 2018, 19 primary school teachers from five low-cost private (LCP) schools in rural Darjeeling were trained to nominate children needing care. Teachers evaluated all of their students aided by a novel tool, 'Behavior Type and Severity Tool' (BTST), completed the Achenbach Teacher Report Form (TRF) as a mental health status reference standard, and nominated two students for care. Sensitivity and specificity of being nominated compared to TRF overall and subdomain scores were calculated. BTST performance was determined by comparing BTST and TRF scores and creating Receiver Operating Characteristic curves to determine optimal cutoffs. Multivariable regression models were used to identify demographic predictors of teacher accuracy using the BTST. Results: For students demonstrating a clinical or borderline score in at least one TRF subdomain, the sensitivity (72%) and specificity (62%) of teacher nomination were moderately high. BTST overall scores and TRF Total Problem scores were correlated (Spearman's ρ = 0.34, p < 0.0001), as were all subdomains. For the TRF Total Problem score, a maximum Youden's J of 0.39 occurred at BTST cutoff >4 for borderline struggles and 0.54 at the BTST cutoff >6 for clinical struggles. Younger teacher age, less education, less formal education training, and more years of experience were positively associated with teacher accuracy. Conclusions: With training and a simple decision support tool, primary school teachers in an LMIC nominated students for mental health services with moderate accuracy. With the BTST being weakly accurate, teachers' judgment largely accounted for the moderate accuracy of nominations.

Perceptions, attitudes, and knowledge of teachers serving as mental health lay counselors in a low and middle income country: a mixed methods pragmatic pilot study

Background

Low and middle-income countries (LMICs) lack trained child mental health professionals. While teachers’ child development experience potentially positions them to fill the gap as lay mental health counselors, they have rarely delivered indicated child mental health care in LMICs. As part of assessing the feasibility of teachers serving as lay counselors, we explored teachers’ perceptions of serving as lay counselors and their mental health attitudes and knowledge.

Methods

In 2018, with training and supervision, 19 primary school teachers from five rural, low cost private schools in Darjeeling, India, served as lay counselors in their classrooms. Using mixed methods, we examined teacher perceptions of serving as lay counselor and mental health attitudes and knowledge through a survey (n = 15), a summative assessment (n = 14), and semi-structured interviews (n = 17). For the survey and summative assessment, pre-training, post-training, and post-intervention mean scores were compared using paired t tests. Post-intervention interviews were coded for teachers’ perceptions of serving as lay counselor and mental health attitudes and knowledge.

Results

Qualitatively, teachers expressed being willing to serve as lay counselor, having more inclusive mental health attitudes, and retaining mental health knowledge as applicable to use during instructional time or incorporation into the knowledge transfer process, their primary duty. By contrast, quantitatively, teachers’ attitudes appeared to become more inclusive on the study-specific survey pre versus post-training, but reverted to pre-training levels post-intervention. Teachers’ mental health knowledge on the summative assessment did not change pre-training versus post-training versus post-intervention.

Conclusions

Training, supervision, and serving as lay counselors led to teachers’ willingness to serve as lay counselors. Teachers served as lay counselors by utilizing therapeutic techniques during class time and incorporating them into their typical instruction, not through delivering traditional office-like care. Teacher practices may be pointing to the potential emergence of an “education as mental health therapy” system of care. Their changes in attitudes and knowledge reflected their emerging practices. Quantitative measures of knowledge and attitude changes did not capture these nuanced changes.

Trial Registration The parent feasibility trial was registered on January 01, 2018 with Clinical Trials Registry – India (CTRI), reg. no. CTRI/2018/01/011471, ref. no. REF/2017/11/015895. http://ctri.nic.in/Clinicaltrials/pdf_generate.php?trialid=21129&EncHid=&modid=&compid=%27,%2721129det%27..

Supplementary Information

The online version contains supplementary material available at 10.1186/s13033-021-00453-3.

The Potential Emergence of "Education as Mental Health Therapy" as a Feasible Form of Teacher-Delivered Child Mental Health Care in a Low and Middle Income Country: A Mixed Methods Pragmatic Pilot Study

Objective: We assessed task-shifting children's mental health care to teachers as a potential approach to improving access to child mental health care. Methods: In Darjeeling, India, we conducted a single-arm, mixed-methods feasibility study with 19 teachers and 36 children in five rural primary schools to determine whether teachers can deliver transdiagnostic mental health care to select children-in-need with fidelity to protocol, to assess which therapeutic options teachers chose to use within the protocol, and to evaluate for a potential signal of efficacy. Results: Participation rates for intervention activities were >80%. A majority of teachers met or exceeded quality benchmarks for all intervention activities. Teachers chose to deliver teacher-centric techniques, i.e., techniques that only teachers could deliver given their role in the child's life, 80% of the time. Children improved in mental health score percentiles on the Achenbach Teacher Report Form. Key facilitators included the flexibility to adapt intervention activities to their needs, while identified barriers included limited time for care delivery. Conclusion: Findings support the feasibility of task-shifting children's mental health care to classroom teachers in resource-limited schools. Fidelity to protocol appeared feasible, though the freedom to choose and adapt therapeutic techniques may also have enhanced feasibility. Surprisingly, teachers consistently chose to deliver teacher-centric therapeutic techniques that resulted in a potential signal of efficacy. This finding supports the potential emergence of "education as mental health therapy" (Ed-MH) as a new therapy modality. Continued investigation is required to test and refine strategies for involving teachers in the delivery of transdiagnostic mental health care.

Behavioral Interventions can Mitigate Adverse Pregnancy Outcomes Among Women Conceiving on ART and Those Initiated on ART During Pregnancy: Findings From the MOTIVATE Trial in Southwestern Kenya

BACKGROUND

Antiretroviral therapy (ART) is essential for the elimination of mother-to-child transmission and improved health outcomes for women living with HIV (WLWH). However, adverse pregnancy outcomes (APOs) among pregnant women on ART are a growing concern.

METHODS

We investigated the associations between timing of ART initiation and APOs among pregnant WLWH receiving behavioral interventions (community mentor mothers and text messaging) in the Mother-Infant Visit Adherence and Treatment Engagement (MOTIVATE) study in southwestern Kenya. Log binomial models were used for estimation of relative risks (RRs) (adjusted for the clustered nature of data) evaluating APOs with 3 exposure comparisons: (1) preconception ART initiation vs. postconception initiation; (2) among postconception ART initiating women, comparisons across gestational ages at cART initiation (first versus second and third trimester exposure), and (3) intervention allocation.

RESULTS

Of the 1275 women included in this analysis, 388 (30%) had an APO: 306 preterm births, 38 low birth weight infants, 33 stillbirths, and 11 miscarriages. In multivariable analysis, viral load ≥1000 copies/mL, moderate and severe anemia at baseline increased risk of APOs. Among women initiating ART before and after conception, no difference was observed in the composite APO. Women who received community mentor mother visits alone (aRR 0.74: 95% CI: 0.71 to 0.76) or text messages alone (aRR 0.79: 95% CI: 0.70 to 0.89) had lower risks of experiencing any APOs.

CONCLUSIONS

Receiving supportive behavioral interventions may mitigate the risk of experiencing an APO among WLWH on ART. Further studies are needed to investigate the underlying mechanisms and optimize the benefits of these interventions.

993. Risk Factors for Periconception Non-Suppression Among Women Living with HIV in Kisumu, Kenya

Background

Pregnant and postpartum women living with HIV (WLHIV) are a priority population for virologic monitoring and efforts to ensure viral suppression to reduce the risk for vertical-transmission and poor maternal health outcomes. Few studies have examined the role of parity on viral suppression during periconception in WLHIV.

Methods

We present data from the ongoing Opt4Mamas study which enrolled pregnant women with HIV on antiretroviral therapy between March and November 2019 attending antenatal care in five public health facilities in Kisumu County, Kenya. We evaluated associations between various sociodemographic and psychosocial factors and periconception viral suppression (< 40 copies/mL) within 12 months of study enrollment. We conducted univariate and multivariate logistic regressions, calculating odds ratios (OR) and 95% confidence intervals (CI).

Results

Among 497 women enrolled, mean age 29.9 years, 301 (61%) had viral load results available within 12 months of study enrollment. Viral loads were available a median of 18 days from conception (interquartile range 71 days before to 90 days after conception), and 237 women (79%) were virally suppressed. The majority (90%) of women were on a non-nucleoside reverse transcriptase inhibitor and 23 (9%) were on a protease inhibitor-containing regimen. In univariate analysis, women younger than 25 and primigravida women were less likely to be virally suppressed (OR 0.31, 95% CI [0.16 - 0.60] and OR 0.25, 95% CI [0.11 - 0.61] respectively; Table 1). The relationship between primigravida and periconception viral suppression is modified by age and duration on ART. Primigravida women who were younger than 25 years or who had less than 1 year of ART had significantly reduced odds of achieving viral suppression in the past year compared to primigravida women who were older or who had more experience taking ART (OR 0.09, 95%CI [0.03-0.31] and OR 0.09, 95%CI [0.02-0.48] respectively; Table 2).

Table 1: Comparison of Pregnant Women with HIV by Periconception Viral Suppression

Table 2: Interaction Effects with Primigravida Status

Conclusion

Risk factors for non-suppression around the time of conception in WLHIV include primigravida status, which is modified by age and duration on ART. Interventions targeting viral suppression among WLHIV leading up to their first pregnancy are needed, particularly among those who are newly initiated onto ART or younger age.

Disclosures

All Authors: No reported disclosures

Male partner involvement and successful completion of the prevention of mother-to-child transmission continuum of care in Kenya

OBJECTIVE

To examine the relationship between male partner involvement (MPI) in prevention of mother-to-child transmission (PMTCT) activities and successful completion of the PMTCT continuum of care, which remains sub-optimal in settings with high prevalence of HIV.

METHODS

A cross-sectional survey was administered in June-August 2017 to a sample of 200 postpartum Kenyan women with HIV enrolled in a parent trial. Composite PMTCT and MPI variables were created. Descriptive, simple and multivariable regression, and mediation analyses were performed.

RESULTS

Of the women, 54% reported successful completion of PMTCT. Depression and internalized HIV stigma were independently associated with lower likelihood of successful completion of PMTCT (adjusted risk ratio [aRR] 0.97; 95% confidence interval [CI] 0.94-0.99; aRR 0.92; 95% CI 0.88-0.98, respectively). Each MPI activity was associated with 10% greater likelihood of successful completion of PMTCT (P < 0.05). The relationship between MPI and the successful completion of PMTCT was partially mediated through women's reduced internalized HIV stigma (β -0.03; 95%CI -0.06 to -0.00).

CONCLUSION

Greater MPI in PMTCT activities has direct and indirect effects on women's successful completion of all necessary steps across the PMTCT continuum. Reduced internalized HIV stigma is likely a key mechanism in the relationship.

Effects of Depression, Stigma and Intimate Partner Violence on Postpartum Women's Adherence and Engagement in HIV Care in Kenya

We explored the association between HIV-related stigma and experiences of intimate partner violence (IPV) and depression with viral load suppression, and medication and visit adherence in postpartum women receiving lifelong antiretroviral therapy (ART) (N = 200). We administered a cross-sectional survey to 200 women with HIV at 12 months postpartum who were enrolled in the MOTIVATE trial. The MOTIVATE study is a cluster-randomized trial evaluating the impact of community mentor mothers and text messaging on PMTCT outcomes in southwestern Kenya. Simple and multivariable logistic regression analysis was performed in STATA. Women who experienced stigma or IPV were more likely to miss clinic visits (internalized stigma aOR 1.30 95%CI 1.03-1.64; anticipated stigma aOR 1.20 95%CI 1.04-1.42; IPV aOR 15.71 95%CI 1.47-167.80), report difficulty taking ART drugs (internalized stigma aOR 1.32 95%CI 1.10-1.58; anticipated stigma aOR 1.14 95%CI 1.01-1.30) and not taking medication as prescribed (IPV aOR 2.00 95%CI 1.05-3.74). Depression was additionally associated with decreased odds of viral load suppression (aOR 0.16 95%CI 0.04-0.76). There is need to develop tailored psychosocial interventions within PMTCT programs that appropriately address mental health, stigma, and violence.

HIV status disclosure patterns and male partner reactions among pregnant women with HIV on lifelong ART in Western Kenya

Disclosure of HIV status to sexual partners in the context of prevention of mother-to-child transmission (PMTCT) may contribute to improved PMTCT outcomes. We administered a questionnaire to 200 women with HIV enrolled in a PMTCT study during pregnancy at 12 months after birth in Western Kenya between May-September 2017. Descriptive analysis of disclosure patterns and multivariate analysis of factors associated with male partner reactions is presented. Among 180 (90%) women who reported having a male partner, 95.5% reported disclosing their HIV status to that partner. The majority of women (82.8%) reported disclosure occurred within one year of their diagnosis, with 62.7% occurring within one week. The most common forms of disclosure were: self-disclosure (55.4%), during couple's HIV testing and counseling (CHTC) (31.5%), or at an antenatal care visit (7.7%). Most women (87.5%) reported that male partner reactions to their HIV status disclosure were positive. Those with negative reactions reported their partners were confused, annoyed, or threatened to leave, however there were no reports of intimate partner violence (IPV) or break ups. Disclosure via CHTC was associated with a positive male partner reaction compared to self-disclosure (adjusted OR (aOR) 20.2, 95% Confidence Interval (CI) 1.8-221.4). Those in concordant HIV status partnerships were more likely to have a positive reaction (aOR. 6.7, 95% CI 1.7-26.6). Women experiencing frequent verbal IPV were less likely to report a positive response (aOR 0.21, 95%CI 0.1-0.8). Most postpartum women with HIV in this cohort had disclosed to their male partners early after diagnosis and experienced a positive reaction. However, a minority had still not disclosed by 12 months after the birth and some experienced negative reactions to disclosure. The form of status disclosure and impact of intimate partner violence should be given greater attention within the context of PMTCT.

An mHealth pilot designed to increase the reach of prevention of mother-to-child transmission of HIV (PMTCT) across the treatment cascade in a resource-constrained setting in Tanzania

BACKGROUND

Data collection and integrated reporting between the multiple health facilities for supporting more efficient care linkages is an indispensable element for prevention of mother-to-child transmission of HIV (PMTCT) by fostering continuity of patient care and improving the treatment cascade for HIV-infected pregnant women. mHealth potentially presents timely solutions to the data challenges related to efficient and effective care delivery in resource-constrained settings, particularly in low- and middle-income countries.

METHODS

This randomized controlled pilot study used stratified random sampling for the selection of seven intervention and seven control sites in Misungwi, Tanzania, a rural district in the northwestern region. Twenty-eight health workers at seven intervention health facilities used the Tanzania Health Information Technology (T-HIT) system during a 3-month period from February 23, 2015, through May 23, 2015, to capture antenatal, delivery, and postnatal patient visits.

RESULTS

T-HIT was designed for use on tablets with the goal to improve reporting, surveillance and monitoring of HIV rates and care delivery in the remote and rural settings. Health workers successfully recorded 2,453 visits. Of these, 1,594 were antenatal visits, 484 deliveries were recorded, and 375 were postnatal visits. Within the antenatal visits, 96% of women had a single visit (1474). Healthcare workers were unable to test 6.7% of women antenatally for HIV.

CONCLUSION

The T-HIT pilot demonstrated the feasibility for implementing an mHealth integrated solution in a rural, low-resource setting that links tablet-based surveillance, health worker capacity-building and patient reminders into a single robust and responsive system. Although the implementation phase was only three months, the pilot generated evidence that T-HIT has potential for improving patient outcomes by providing more comprehensive, linked, and timely PMTCT care data at the individual and clinic levels.

Intimate Partner Violence Against HIV-Positive Women is Associated with Sub-Optimal Infant Feeding Practices in Lusaka, Zambia

Objectives The aim of this study is to determine how intimate partner violence against HIV-positive women affects safe infant feeding practices in Lusaka, Zambia. Methods A cross-sectional face-to-face survey was conducted with 320 married postpartum women at a large public health center in Lusaka, Zambia, in 2014. Variables were measured using previously validated instruments from the Demographic and Health Survey. Data were analyzed using simple and multivariate logistic regression in Stata 12. Results Thirty-seven percent of women report early mixed infant feeding prior to six months. Women who experienced intimate partner violence have 2.8 higher adjusted odds of early mixed infant feeding (p < 0.001). Women who experienced emotional violence, specifically, have 1.9 higher adjusted odds of early mixed infant feeding (p < 0.05), while women who experienced sexual violence have 2.3 higher adjusted odds (p < 0.01). There is also a dose-response relationship between IPV and early mixed infant feeding (p < 0.05). Lastly, disclosing one's HIV-positive status to the husband is associated with at least 67 % lower adjusted odds of early mixed feeding (p < 0.05). Conclusions Intimate partner violence against HIV-positive women, in particular emotional and sexual violence, increases the likelihood of early mixed infant feeding, putting infants at greater risk for both mother-to-child transmission of HIV and other infant morbidities. Intimate partner violence should thus be given increased attention within the context of infant feeding and HIV in sub-Saharan Africa.

Understanding internalized HIV/AIDS-related stigmas in the Dominican Republic: a short report

HIV/AIDS-related stigmas can become internalized, resulting in declines in physical and mental health. Pathways to internalized HIV-related stigma (IS), characterized by persistently negative, self-abasing thoughts, are not well established among women living with HIV/AIDS (WLWHA) in the Dominican Republic (DR). Identifying factors involved in self-directed shaming and blaming is important, given the high HIV prevalence in the DR's most vulnerable populations. The present study sheds light on factors involved in negative and self-abasing thoughts in WLWHA in the DR by examining the relationship between depression, perceived HIV-related stigma from the community (PSC), perceived HIV-related stigma from family (PSF), and IS. The Internalized AIDS-Related Stigma Scale (IA-RSS), the Center for Epidemiologic Studies Short Depression Scale (CES-D 10), and an instrument designed to measure perceived HIV-related stigma from the community and family was administered to 233 WLWHA in Puerto Plata, DR. Data were analyzed using descriptive statistics and ordered multiple logistic regression. Results showed that depression (OR = 1.60; p < .05), PSC (OR = 3.68; p < .001), and PSF (OR = 1.60; p < .01) were positively associated with IS. These findings indicate that IS-reducing interventions should address HIV-related depression. Additionally, HIV-related treatment and care services should work with WLWHA to adopt healthier attitudes about how community members view people living with HIV/AIDS in the DR.

Perceptions of health care services and HIV-related health-seeking behavior among Uganda adolescents

Youth represent almost half of all new HIV infections globally. Although condom use is an effective method of HIV prevention among sexually active youth in sub-Saharan Africa (SSA), they face substantial barriers in obtaining condoms in environments where adults hold attitudes condemning premarital sex. More research is needed to better understand the multitude of factors that affect SSA youths' behaviors regarding safe sex practices, including factors that may influence their ability to obtain condoms, and decisions to be tested for HIV. In this study of Uganda youth (n = 1503) from five secondary schools, logistic regression models highlight factors that influence perceptions regarding respect and confidentiality at health centers, condom acquisition, and HIV testing. Family support appears to be an especially important factor that affects youth perceptions about how they will be treated when seeking condoms and HIV testing. Condom acquisition and HIV-testing behaviors are also associated with peer influence, self-esteem, and demographic characteristics, such as age.

Vertical Transmission of HIV in Sub-Saharan Africa: Applying Theoretical Frameworks to Understand Social Barriers to PMTCT

In sub-Saharan Africa, over 1,000 newborns are infected with HIV every day, despite available medical interventions. Pediatric HIV is a large contributor to the high rates, the largest in the world, of infant and child mortality in this region. Prevention of mother-to-child transmission of HIV (PMTCT) can dramatically reduce the risk of infection for the infant during pregnancy, childbirth, and breastfeeding. Throughout most urban areas of Africa, free medications are readily available. However, approximately 50% of HIV-positive pregnant women in sub-Saharan Africa are not accessing or adhering to the necessary medications to prevent mother-to-child transmission. In order for this region to eliminate the vertical transmission of HIV and meet the Millennium Development Goals, interventions need to move beyond the individual-level and address the structural and social barriers preventing women from utilizing PMTCT services. This paper reviews current literature on PMTCT interventions in sub-Saharan Africa from 2006–2012, specifically examining theoretical underpinnings. Overwhelmingly, the approach has been education and counseling. This paper calls to action a paradigm shift to a social ecological approach that addresses barriers at all societal levels, especially gender inequality, enabling a much greater impact on mother-to-child transmission of HIV.