A group-based mental health intervention for Tanzanian youth living with HIV: Secondary analysis of a pilot trial.

BACKGROUND: Youth living with human immunodeficiency virus (YLWH) are vulnerable to incomplete adherence to antiretroviral therapy in the context of stigma, decreased hope for future, and mental health challenges. Despite these challenges, few mental health interventions have been developed to support YLWH. Previous randomized results from the Sauti ya Vijana (SYV; "The Voice of Youth") mental health intervention were indicative of the intervention's benefits in promoting virologic suppression. METHODS: SYV is a group-based mental health and life skills intervention (pilot, individually randomized group treatment trial) developed alongside YLWH. SYV was comprised of 10, 90-minute sessions based on evidence-based treatment models designed to improve coping, social support, and hope for future as a pathway to improved adherence and virologic suppression. At baseline, YLWH 12 to 24 years of age were randomized to SYV or standard of care. Participants included in this secondary analysis were enrolled in SYV's crossover waves due to either being randomized to standard of care or inability to attend an earlier group, and therefore delayed intervention exposure. Measured outcomes included self-reported mental health measures, self-reported human immunodeficiency virus measures (stigma and adherence), and human immunodeficiency virus ribonucleic acid. Data was collected at baseline, preintervention, and postintervention timepoints. Participants were included if they attended a crossover wave and had data at all 3 timepoints. RESULTS: Twenty-one crossover participants met inclusion criteria. Mean scores of self-reported mental health questionnaires were in an asymptomatic range both pre- and postintervention. Viral suppression was N = 15 (71%) preintervention compared to N = 17 (81%) postintervention. The participants who became virologically suppressed had no change in antiretroviral therapy. CONCLUSIONS: Despite the small sample size, findings from this study demonstrate that mental wellbeing may be an important pathway to improved HIV outcomes for YLWH. The same trend toward virologic suppression pre- to postintervention was demonstrated in the randomized pilot trial and suggests that SYV holds promise to improve HIV outcomes. Data from this analysis support the fully powered trial that is now underway.

Feasibility and acceptability of a peer youth led curriculum to improve HIV knowledge in Northern Tanzania: resilience and intervention experience from the perspective of peer leaders.

BACKGROUND: Youth Living with HIV (YLWH) have reduced adherence to antiretroviral therapy (ART) and worse virologic outcomes compared to children and adults. HIV peer youth led (PYL) interventions contribute to improved retention in care and psychosocial wellbeing. The study objective was to assess the feasibility and acceptability of a PYL HIV curriculum and describe change in participants' knowledge and impact of leadership on peer leaders' lives. METHODS: An HIV curriculum was taught during monthly Saturday adolescent HIV clinics at two clinical sites in Moshi, Tanzania (2018-2019). Youth attending clinics were ages 12 to 24 years and received the HIV curriculum during routine clinical care. Peer leaders previously participated in a mental health and life skills intervention called Sauti ya Vijana (The Voice of Youth; SYV) and were recommended for leadership by SYV facilitators and clinic staff. Peer leaders were trained and supervised weekly in curriculum delivery using a "train the trainer" model. Data were collected and analyzed using mixed methods. Fidelity checklists were used to measure adherence to the curriculum. Youth participants answered written pre- and post-knowledge questions and evaluated PYL teaching. Semi-structured interviews and the Connor Davidson Resilience scale were conducted with peer leaders before and after assuming the leadership role. RESULTS: Peer leaders (N = 4 male; 3 female) demonstrated high fidelity (96%) to activities in each lesson and participant feedback was positive for curriculum delivery. Participants' knowledge improved in nine of ten sessions. All but one leader-who moved away before the study ended-demonstrated stable or improved resilience with a mean difference of 3.8 (SD = 7.0) from before the intervention to after assuming the leadership role. Peer leaders reported improved leadership confidence and resilience, and their perception was that the curriculum helped normalize the HIV experience for YLWH attending clinic. Nevertheless, anticipated stigma, difficulty disclosing HIV status, and teaching ability remained barriers. CONCLUSIONS: This study demonstrated that a PYL curriculum to improve HIV knowledge integrated into routine adolescent HIV clinic in Tanzania was feasible, acceptable, and improved knowledge while also benefiting peer leaders, thus providing evidence to continue to support efforts to scale and sustain PYL interventions for YLWH.

Disparities in Alzheimer Disease and Mild Cognitive Impairment Among Native Hawaiians and Pacific Islanders.

BACKGROUND: Previous studies of racial differences in Alzheimer disease (AD) presentation have not included Native Hawaiians and Pacific Islanders (NHPI). OBJECTIVE: To explore the presentation of AD and mild cognitive impairment (MCI) in NHPI. METHOD: We conducted a retrospective review of patient records from Hawaii with a diagnosis of unspecified AD or MCI from September 2000 to September 2019. Variables of interest included age at diagnosis, gender, race, marital status, insurance, comorbidities, and scores on the Mini-Mental State Examination (MMSE) or the Montreal Cognitive Assessment (MoCA). RESULTS: We reviewed the medical records of 598 patients, including 224 Asians, 202 Whites, 87 NHPI, and 85 Other. AD was more dominant than MCI across all of the groups, with the highest percentage in NHPI. Among the mean ages of diagnosis, NHPI were the youngest. Across all groups, a higher proportion of women than men had AD, with the highest female prevalence among NHPI. Hypertension, hyperlipidemia, and type II diabetes were highest among NHPI compared with the other groups. Of individuals with MMSE/MoCA scores, there were significant variations in scores by racial group. The mean MMSE/MoCA score was highest among Whites and lowest among NHPI. CONCLUSION: Compared with other racial groups, NHPI have a higher proportion of AD than MCI at diagnosis, are diagnosed at a younger age, have a higher female prevalence, have more comorbidities that may contribute to AD/MCI onset, and present with lower MMSE scores.

Livelihood intervention and mental well-being among women living with HIV in Delhi.

ABSTRACTPoverty-alleviation programmes aimed to improved mental well-being among persons living with HIV (PLWH) in low and middle income countries have underscored the importance of understanding how and why such programmes work. We present findings from a six-month ethnographic process evaluation of Kiran, an economic livelihood programme locally designed to improve mental well-being among women affected by HIV in Delhi, India. In addition to benefits of improved economic standing, we found that supportive relationships cultivated among participants (n = 9) and with providers (n = 3) provided respite from worry about their illness and reframed what was relationally and practically possible in the context of living with HIV. In acquiring marketable craft skills with peers, participants challenged internalized scripts of being socially devalued and regained agency about their abilities to contribute to their community and support their children's immediate and future needs. We found that the benefits of Kiran weighed less on the direct alleviation of mental distress and more on the instillation of hope for their children. Our findings exemplify the importance of re-visiting a priori theories that inform interventions for PLWH and highlight the methodological merits of ethnographic approaches that underscore how theory and intervention praxis are bidirectionally informed.

Associations Between Plasma Immunomodulatory and Inflammatory Mediators With VACS Index Scores Among Older HIV-Infected Adults on Antiretroviral Therapy.

The prevalence of age-related comorbidities is increased in people living with HIV, even in those well-controlled on combination antiretroviral therapy (ART). Persistent immune activation and inflammation may play pivotal roles in the pathogenesis; however, the burden of morbidities in the older HIV infected population may be exacerbated and driven by distinct mechanisms. In a cross sectional study of 45 HIV-infected participants 60 years or older, we examined the relationships between 14 immunomodulatory and inflammatory factors and the Veterans Aging Cohort Study (VACS) Index, a metric of multimorbidity and mortality comprised of age, CD4 count, hemoglobin, Fibrosis-4 [FIB-4], and estimated glomerular filtration rate [eGFR], by linear regression analysis. All participants were virally suppressed (<50 HIV RNA copies/mL), on ART, and primarily Caucasian (86.7%), and male (91.1%). Plasma levels of monocyte/macrophage-associated (neopterin, IP-10, sCD163, sCD14, and MCP-1) and glycan-binding immunomodulatory factors (galectin (Gal)-1, Gal-3, and Gal-9) were assessed, as well as inflammatory biomarkers previously linked to the VACS Index (i.e., CRP, cystatin C, TNF-α, TNFRI, IL-6, and D-dimer) for comparison. In regression analysis, higher VACS index scores were associated with higher levels of neopterin, cystatin C, TNFRI, and Gal-9 (all p < 0.05), potentially driven by correlations found with individual VACS components, including age, CD4 count, FIB-4, and eGFR. Gal-9, cystatin C, and TNFRI directly correlated with the extent of multimorbidity. Multiple correlations among markers were observed, suggesting an interplay of overlapping, but distinct, pathways. Collectively, in addition to cystatin C and TNFRI, both galectin-9 and neopterin, independently emerged as novel fluid markers of the VACS Index and burden of comorbidity and may further guide in understanding pathogenic mechanisms of age-related disorders in older HIV-infected individuals on suppressive ART.

Reflections on a community health elective in Native Hawaiian Health: a community-centred vision for health and the medical profession in Indigenous contexts.

The medical profession is fundamentally thought of as a vocation and calling, one that requires the translation of knowledge and skill into counselling, diagnosis and interventions that benefit the lives of patients. Physicians and healthcare professionals have the immense privilege to compassionately use their vocation to improve the health of communities. What does this commitment look like in an Indigenous health setting? Using the author's own experience as a participant-observer in the University of Hawaii's John A. Burns School of Medicine's Native Hawaiian Health elective, an example is provided of an educational curriculum that seeks to integrate community health in Native Hawaiian settings. This paper shows the ways that the author's understanding of health broadened to include environmental stewardship and healthcare professionals' compassion and involvement in the life of the community throughout the elective. By providing this example, the author seeks to shed light on how a medical education initiative can change the way students approach Indigenous health.

Geriatric Syndromes in Older Adults Living with HIV and Cognitive Impairment.

OBJECTIVES: Nearly half of the population living with human immunodeficiency virus (HIV) in the United States is now older than 50 years with at least 6% over age 65. Between 35% and 50% live with mild to moderate cognitive impairment. Older persons living with HIV (PLWH) also have a substantial burden of HIV-associated non-acquired immunodeficiency syndrome medical conditions and are at risk for frailty, geriatric syndromes, and early mortality compared with HIV-uninfected peers. We sought to define the magnitude of geriatric conditions and multimorbidity in PLWH older than 60 years who are living with symptomatic cognitive impairment. In a subset of participants, we examined associations between these geriatric conditions. DESIGN: Retrospective cohort study. SETTING: HIV Elders Study at the University of California, San Francisco, Memory and Aging Center. PARTICIPANTS: Participants were HIV infected, virally suppressed, 60 years or older, and clinically diagnosed with mild neurocognitive disorder (MND). MEASUREMENTS: We conducted standardized assessment of geriatric conditions and everyday function and investigated multimorbidity burden using the Veterans Aging Cohort Study (VACS) index. RESULTS: Among 141 older PLWH with MND, 58% report incontinence, 55% meet criteria for pre-frailty, and a substantial proportion report dependence with instrumental activities of daily living (52%) or activities of daily living (41%). The mean VACS index score is 33 (standard deviation = 14), suggesting a 13.8% 5-year all-cause mortality risk. CONCLUSIONS: Older PLWH with symptomatic cognitive impairment carry a substantial burden of other geriatric conditions. Our work supports the need for comprehensive geriatric systems of care for cognitively impaired individuals aging with HIV. J Am Geriatr Soc 67:1913-1916, 2019.