A systematic comparison of additive and interaction approaches to modeling the effects of syndemic problems on HIV outcomes in South Africa.

Much of the research on the effects of syndemics on HIV outcomes has utilized an additive approach. However, interaction effects may better account for syndemic synergy than an additive approach, but it remains difficult to specify interaction effects without empirical guidance. We sought to systematically compare additive and interaction effects approaches to modeling the effects of syndemic problems on antiretroviral therapy (ART) using empirically specified interaction terms. Participants were 194 people with HIV (PWH) who received HIV care in Khayelitsha, South Africa. In a series of linear regression models, we examined ten syndemic problems: depression, alcohol use, intimate partner violence (IPV), post-traumatic stress, social anxiety, substance use, food insecurity, poverty, housing instability, and structural barriers to care. Depression, substance use, and food insecurity were selected for interaction terms based on a prior network analysis, which found these problems to be most central. The additive models did not produce statistically significant findings. However, the interaction effects models yielded significant interaction terms in both the full model and a parsimonious model. There was a statistically significant effect of the interaction between depression and food insecurity on ART adherence (b = 0.04, Robust SE = 0.02, 95%CI [0.001-0.08], p = .012). This pattern of results was replicated in the parsimonious model. Findings suggest that when feasible, interaction effects approaches may be a helpful syndemic modeling technique. Results may inform future intervention targets, such as depression and food insecurity, and the importance of addressing both structural and psychosocial syndemic problems.

Barriers, Facilitators, and Strategies to Improve Participation of a Couple-Based Intervention to Address Women's Antiretroviral Therapy Adherence in KwaZulu-Natal, South Africa.

BACKGROUND: Couple-based interventions (CBIs), despite strong efficacy in improving numerous HIV risk behaviors, are not widely available and have not been tested to improve women's antiretroviral therapy (ART) adherence. We examined barriers and facilitators to participation in a CBI based on cognitive behavioral couple therapy for women's ART adherence in KwaZulu-Natal, South Africa. METHODS: Semi-structured interviews were conducted with women with HIV (n = 15) and men of mixed HIV status (n = 15). Thematic analyses were guided by the Consolidated Framework for Implementation Research. RESULTS: Facilitators mostly related to the couple's relationship, including having an existing healthy relationship, men's desire to support their partners, and a potential opportunity for men's HIV disclosure. Barriers included a lack of understanding of how a CBI approach would be useful for women's ART adherence, sole focus on women if male partners were also living with HIV, and men's lack of prior HIV status disclosure to female partners. CONCLUSION: Findings indicate that relationship context and the male partner's HIV status need to be addressed during recruitment, enrolment, and during the intervention to promote uptake.

Raising the issue of quality in implementation science reporting in global health: Implications for health planning and practice.

Implementation outcomes, which focus on the barriers to, and facilitators and processes of healthcare delivery, are critical to translating research evidence to health planning and practice and to improving healthcare delivery. This article summarises key quality issues in reporting of implementation science outcomes within global health and describes the ways in which this presents a challenge for shifting health planning and practice across low-resource health systems. This article also suggests that the wider use of reporting guidelines for implementation outcomes could help address this issue.

Adapting a Behavioral Activation Intervention for Opioid Use Disorder and Methadone Treatment Retention for Peer Delivery in a Low-Resource Setting: A Case Series.

While methadone treatment (MT) is effective in treating opioid use disorder (OUD), retention remains an issue nationwide, especially among low-income, minoritized populations. Peer recovery specialists (PRSs), individuals with lived substance use experience, are particularly well suited to support vulnerable populations, though often are not trained in delivering evidence-based interventions. Thus, our team developed a Type 1 hybrid effectiveness-implementation open-label pilot trial to evaluate the effectiveness of PRS-delivered BA (Peer Activate) in improving MT retention and establish feasibility, acceptability and PRS fidelity of the intervention. In this case series, we provide a more in-depth depiction of the adaption of Peer Activate and present three cases to illustrate how Peer Activate can be implemented among patients in routine MT care and adapted to meet the needs of varying clinical presentations. We include descriptive data on participant substance use and MT outcomes to supplement the narrative discussion. While varying participant presentations and needs presented challenges to the PRS interventionist, the PRS utilized his shared, lived substance use and recovery experiences and met participants where they were at, as well as successfully used BA techniques, ultimately leading to intervention success.

Intersecting Relationships of Psychosocial and Structural Syndemic Problems Among People with HIV in South Africa: Using Network Analysis to Identify Influential Problems.

In South Africa, little is known about interrelationships between syndemic problems among people with HIV (PWH). A better understanding of syndemic problems may yield important information regarding factors amenable to mitigation. We surveyed 194 PWH in Khayelitsha, outside of Cape Town, South Africa. We used network analysis to examine the frequency of 10 syndemic problems and their interrelationships. Syndemic problems among PWH in South Africa were common; 159 (82.8%) participants reported at least 2 co-occurring syndemic problems and 90 (46.9%) endorsed 4 or more. Network analysis revealed seven statistically significant associations. The most central problems were depression, substance use, and food insecurity. Three clusters of syndemics were identified: mood and violence; structural factors; and behavioral factors. Depression, substance use, and food insecurity commonly co-occur among PWH in sub-Saharan Africa and interfere with HIV outcomes. Network analysis can identify intervention targets to potentially improve HIV treatment outcomes.

RESUMEN: En Sudáfrica, poco se sabe sobre interrelaciones entre problemas sindémicos entre personas con VIH (PCV). Un major entendimiento de los problemas sindémicos puede arrojar información importante sobre los factores susceptibles de mitigación. Utilizamos el análisis de redes para examinar la frecuencia de 10 problemas sindémicos y sus interrelaciones. Problemas sindémicos entre PCV en Sudáfrica eran communes; 159 (82.8%) participantes presentaron al menos 2 problemas sindémicos concurrentes y 90 (46.9%) presentaron 4 o más. El análisis de red reveló siete asociaciones estadísticamente significativas. Los problemas más centrales fueron la depresión, el uso de sustancias y la inseguridad alimentaria. Se indetificaron tres grupos de sindemias: estado de ánimo y violencia; factores estructurales; y factores de comportamiento. La depresión, el uso de sustancias y la inseguridad alimentaria comúnmente ocurren simultáneamente entre las PCV en el África subsahariana e interfieren con los resultados del VIH. El análisis de redes puede identificar objetivos de intervención para potencialmente mejorar los resultados del tratamiento del VIH.

The Role of Peer Providers to Scale Up Psychological Treatments for Perinatal Populations Worldwide.

PURPOSE OF REVIEW: Psychological treatments remain largely inaccessible to perinatal populations despite their robust effectiveness. This gap is partly due to the limited number of available treatment providers. In this review, we critically evaluate recent literature on task-sharing to peer providers and propose future directions. RECENT FINDINGS: There is a growing evidence base demonstrating that peer providers can effectively deliver psychological treatments for perinatal populations, as well as engage in processes critical to quality assurance, such as measurement-based peer supervision. Findings have also highlighted some benefits of peers over licensed healthcare providers, such as enhanced collaborative relationships, reduced stigma, provision of social comparisons, and increased accessibility. Peer providers may be one solution to improve access to psychological treatments for perinatal populations. However, there is a need to address clinical, professional, and health-system level barriers to effectively leverage this cadre of treatment providers.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment.

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].

Randomized Controlled Pilot Trial of a Low-Touch Remotely-Delivered Values Intervention to Promote Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors.

BACKGROUND: Oral anti-cancer treatments such as adjuvant endocrine therapies (AET) for breast cancer survivors are commonly used but adherence is a challenge. Few low-touch, scalable interventions exist to increase ET adherence. PURPOSE: To evaluate the acceptability, feasibility, and initial efficacy of a low-touch, remotely-delivered values plus AET education intervention (REACH) to promote AET adherence. METHODS: A mixed-methods trial randomized 88 breast cancer survivors 1:1 to REACH or Education alone. Wisepill real-time electronic adherence monitoring tracked monthly AET adherence during a 1-month baseline through 6-month follow-up (FU) (primary outcome). Patient-reported outcomes were evaluated through 3- and 6-month FU (secondary). Multiple indices of intervention feasibility and acceptability were evaluated. Qualitative exit interviews (n = 38) further assessed participants' perceptions of feasibility/acceptability and recommendations for intervention adaptation. RESULTS: The trial showed strong feasibility and acceptability, with an eligible-to-enrolled rate of 85%, 100% completion of the main intervention sessions, and "good" intervention satisfaction ratings on average. For Wisepill-assessed AET adherence, REACH outperformed Education for Month 1 of FU (p = .027) and not thereafter. Participants in REACH maintained high adherence until Month 4 of FU, whereas in Education, adherence declined significantly in Month 1. Conditions did not differ in self-reported adherence, positive affective attitudes, future intentions, or necessity beliefs. REACH trended toward less negative AET attitudes than Education at 3-month FU (p = .057) reflecting improvement in REACH (p = .004) but not Education (p = .809). Exploratory moderator analyses showed that average to highly positive baseline AET affective attitudes and oncologist-patient communication each predicted higher adherence following REACH than Education; low levels did not. Participants identified recommendations to strengthen the interventions. CONCLUSIONS: REACH, a low-touch values intervention, showed good feasibility and acceptability, and initial promise in improving objectively-assessed AET adherence among breast cancer survivors (relative to education alone). Future research should target improving REACH's tailoring and endurance.

Act Healthy: A Randomized Clinical Trial Evaluating a Behavioral Activation Intervention to Address Substance Use and Medication Adherence Among Low-Income, Black/African American Individuals Living with HIV/AIDS.

There is a need for parsimonious behavioral interventions to support HIV and substance use treatment outcomes for low-income, Black/African American individuals living with HIV. This randomized clinical trial (N = 61) evaluated Act Healthy (AH), an integrated behavioral intervention to reduce substance use and improve medication adherence, compared to supportive counseling (SC) plus Life-Steps medication adherence counseling on substance use, craving, adherence-related outcomes, and depression over one year. Participants in AH had significantly steeper decreases in cravings compared to SC, but no significant differences in substance use. Across both groups, there was a significant increase in probability of being on antiretroviral therapy (ART) (86% on ART at 12 months vs. 56% at baseline), and a significant decrease in medication nonadherence. Findings provide preliminary support for an intervention to reduce cravings and strategies to improve ART use in a hard-to-reach, vulnerable population at high risk for poor treatment outcomes and ongoing HIV transmission. TRIAL REGISTRATION: ClinicalTrials.gov trial registration number: identifier: NCT01351454. Retrospectively registered on May 10, 2011.

Gender Moderates Results of a Randomized Clinical Trial for the Khanya Intervention for Substance Use and ART Adherence in HIV Care in South Africa.

Little is known about gender effects of alcohol and drug use (AOD) among people living with HIV (PLWH) in resource-limited settings. Using multilevel models, we tested whether gender moderated the effect of Khanya, a cognitive-behavioral therapy-based intervention addressing antiretroviral (ART) adherence and AOD reduction. We enrolled 61 participants from HIV care and examined outcomes at 3- and 6-months compared to enhanced treatment as usual (ETAU). Gender significantly moderated the effect of Khanya on ART adherence (measured using electronically-monitored and biomarker-confirmed adherence), such that women in Khanya had significantly lower ART adherence compared to men in Khanya; no gender differences were found for AOD outcomes. Exploratory trajectory analyses showed men in Khanya and both genders in ETAU had significant reductions in at least one AOD outcome; women in Khanya did not. More research is needed to understand whether a gender lens can support behavioral interventions for PLWH with AOD.Trial registry ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.

The Relationship Between Harmful Alcohol Use and Antiretroviral Non-adherence in People Accessing HIV Treatment in Cape Town, South Africa: An Event-Level Analysis.

Harmful alcohol consumption can significantly compromise adherence to antiretroviral therapy (ART). Prior research has identified aggregate relationships between alcohol use and ART non-adherence, largely relying on concurrent assessment of these domains. There is relatively limited evidence on more nuanced day-level associations between alcohol use and ART non-adherence, despite potentially important clinical implications. We recruited adults with HIV treatment adherence challenges and harmful alcohol use (n = 53) from HIV care in South Africa. We examined relationships between alcohol use and same and next day ART adherence, accounting for the role of weekends/holidays and participant demographics, including gender. Results demonstrated that ART adherence was significantly worse on weekend/holiday days. Next day adherence was significantly worse in the context of weekend alcohol use and among men. These results suggest the importance of tailoring intervention strategies to support ART adherence during weekend drinking and for men engaged in heavy episodic drinking.

Implementing Task-Shared Child and Adolescent Psychological Interventions in Low- and Middle-Income Countries: A Scoping Review.

OBJECTIVE: Effective "task shared," or nonspecialist delivered, psychological interventions for children and adolescents have been developed or adapted in low- and middle-income countries with the aim of closing the global treatment gap for youth mental health care. Yet, delivery remains limited, in part due to the lack of knowledge of associated implementation, or process, outcomes. This scoping review aims to describe, examine the quality of, and synthesize findings on implementation outcomes of child and adolescent psychological interventions in low-and middle-income countries. METHODS: PubMed, Web of Science, and PsycInfo were searched for studies on child and adolescent psychological interventions in low- and middle-income countries reporting on implementation outcomes. After abstract and full-text review, data were extracted and summarized on implementation outcomes and quality of implementation outcomes reporting. Implementation barriers and recommendations for addressing barriers were also charted and narratively synthesized. RESULTS: Out of 5,207 manuscripts, 86 met inclusion criteria. Younger children were underrepresented. Studies largely reported feasibility and acceptability and did not state hypotheses or use conceptual models. Barriers primarily related to interventions being too complex, not an acceptable fit with participant cultures, and facilitators lacking time for or experiencing distress delivering interventions. Recommendations focused on increasing intervention fit and flexibility, training and support for facilitators, and linkages with existing systems. CONCLUSIONS: Rigorous, broader implementation outcomes research is needed within child and adolescent psychological intervention research in low-and middle-income countries. Current evidence suggests the importance of the further developing strategies to increase acceptability to participants and better support facilitators.

Adapting a Behavioral Intervention for Alcohol Use and HIV Medication Adherence for Lay Counselor Delivery in Cape Town, South Africa: A Case Series.

Human immunodeficiency virus (HIV) and problematic alcohol use are two ongoing and interconnected epidemics in South Africa, with untreated problematic alcohol use associated with poorer HIV treatment outcomes and disease progression. A lack of trained mental health providers is a primary barrier to increasing access to evidence-based treatment in this setting. To address this gap, we integrated evidence-based intervention components for problematic alcohol use and antiretroviral therapy (ART) adherence, adapted for lay provider delivery in an HIV primary care setting in Cape Town, South Africa. The intervention, locally termed "Khanya" in isiXhosa, which means glow, direction, or light, comprises Life Steps adherence counseling, motivational interviewing, behavioral activation, and relapse prevention, including mindfulness-based relapse prevention components. In this case series, we present a detailed description of the intervention and provide three clinical cases of individuals who received the Khanya intervention to showcase necessary clinical adaptations and the supervision needed for optimal treatment delivery, flexibility in intervention delivery, and overall successes and challenges. We present descriptive data on alcohol use and ART adherence outcomes for the cases to supplement the narrative discussion. Successes of intervention delivery included participant uptake of mindfulness skills, reductions in alcohol use despite varying levels of motivation, and interventionist mastery over various clinical skills. Challenges included delivering the intervention within the allotted time and the strong influence of substance-using social networks. Overall, a pragmatic approach to intervention delivery was necessary, as was ongoing support for the interventionist to promote fidelity to both treatment components and therapeutic skills. Trial registration: ClinicalTrials.gov identifier: NCT03529409. Trial registered on May 18, 2018.

Improving the measurement of food insecurity among people with HIV in South Africa: a psychometric examination.

OBJECTIVE: Food insecurity is a structural barrier to HIV care in peri-urban areas in South Africa (SA), where approximately 80 % of households are moderately or severely food insecure. For people with HIV (PWH), food insecurity is associated with poor antiretroviral therapy adherence and survival rates. Yet, measurement of food insecurity among PWH remains a challenge. DESIGN: The current study examines the factor structure of the nine-item Household Food Insecurity Access Scale (HFIAS, isiXhosa-translated) among PWH in SA using a restrictive bifactor model. SETTING: Primary care clinics in Khayelitsha, a peri-urban settlement in Cape Town, SA. PARTICIPANTS: Participants (n 440) were PWH who received HIV care in Khayelitsha screening for a clinical trial. Most were categorised as severely (n 250, 56·82 %) or moderately (n 107, 24·32 %) food insecure in the past 30 d. RESULTS: Revised parallel analysis suggested a three-factor structure, which was inadmissible. A two-factor structure was examined but did not adequately fit the data. A two-factor restrictive bifactor model was examined, such that all items loaded on a general factor (food insecurity) and all but two items loaded on one of two specific additional factors, which adequately fit the data (comparative fit index = 0·995, standardised root mean square residual = 0·019). The two specific factors identified were: anxiety/insufficient quality and no food intake. Reliability was adequate (ω = 0·82). CONCLUSIONS: Results supported the use of a total score, and identified two specific factors of the HFIAS, which may be utilised in future research and intervention development. These findings help identify aspects of food insecurity that may drive relationships between the construct and important HIV-related variables.

Implementing a peer recovery coach model to reach low-income, minority individuals not engaged in substance use treatment.

Background: Low-income, racial/ethnic minority individuals face significant barriers in access to substance use (SU) treatment. Peer recovery coaches (PRCs), individuals with lived experience with substance use disorder (SUD), may be uniquely well suited to assist those encountering barriers to treatment. PRCs can also help reach those not engaged in treatment to promote harm reduction and support linkage-to-care when embedded in community rather than clinical settings. This study evaluated a community-based program in which a PRC facilitated linkage to and supported retention in SU treatment. Methods: Guided by the RE-AIM framework, we evaluated implementation of the intervention in a community resource center (CRC) serving homeless and low-income residents of Baltimore City. We examined the reach, effectiveness, adoption, and implementation of this PRC model. Results: Of 199 clients approached by or referred to the PRC, 39 were interested in addressing their SU. Of those interested in addressing SU, the PRC linked 64.1% (n = 25) to treatment and was able to follow up with 59.0% (n = 23) at prespecified time points after linkage (24-48 hours, 2 weeks, and 1 month). Fifty-two percent (n = 13) of clients linked to SU treatment remained in treatment at 30 days post-linkage. Of clients who did not remain in treatment, 77% (n = 10) continued contact with the PRC. Conclusions: Results indicate the utility of the CRC's approach in linking people to treatment for SU and addressing barriers to care through work with a PRC. Findings also highlight important barriers and facilitators to implementation of this model, including the need for adaptation based on individual goals and fluctuations in readiness for treatment.

Tryptophan degradation is associated with risk-taking propensity in methamphetamine users with treated HIV infection.

Few studies have examined neuroimmune pathways that could contribute to impulsivity in people living with HIV who use substances. Eighty-four methamphetamine-using, sexual minority men with an undetectable HIV viral load were administered the Balloon Analogue Risk Task (BART), a behavioral measure of risk-taking propensity. We examined the associations between kynurenine/tryptophan ratio and phenylalanine/tyrosine ratio with BART scores using multiple linear regression. A higher kynurenine/tryptophan ratio was independently associated with greater BART scores (beta = 0.25; 95% CI = 0.05-1.23; p = 0.034). The phenylalanine/tyrosine ratio was not significantly associated with BART scores. Findings support the need for further research to elucidate the neuroimmune mechanisms linking tryptophan degradation with impulsivity to catalyze the development novel pharmacologic treatments for people living with HIV who use methamphetamine.

"Now We Are Told That We Can Mix": Messages and Beliefs Around Simultaneous Use of Alcohol and ART.

South Africa (SA) has the most people living with HIV/AIDS (PLWH) globally and prevalent alcohol use. Beliefs that mixing alcohol and antiretroviral therapy (ART) can lead to adverse reactions may promote ART nonadherence. Healthcare providers (n = 11) and patients (n = 19) recruited from primary HIV and substance use care in SA described their messages, beliefs, and behaviors around simultaneous use of alcohol and ART. Transcripts were analyzed using thematic analysis: (1) most providers indicated a message shift to reflect harm reduction principles: PLWH should manage alcohol use but not let it interfere with taking ART; however, (2) patients recalled conflicting messages from their providers and some displayed interactive toxicity beliefs and behaviors. Despite progress demonstrated by 2016 national adherence guidelines and shifted provider messaging, interactive toxicity beliefs remain a barrier to ART adherence. Results have implications for the adaptation of adherence counseling to minimize the impact of alcohol use on HIV treatment.

A Task-Shifting Problem-Solving Therapy Intervention for Depression and Barriers to Antiretroviral Therapy Adherence for People Living With HIV in Zimbabwe: Case Series.

HIV is prevalent in Sub-Saharan Africa, and depression frequently co-occurs. Depression is one of the most important predictors of poor adherence to antiretroviral therapy (ART). Little has been done to develop integrated interventions that are feasible and appropriate for task-shifting to nonspecialists that seek to address both depression and barriers to ART adherence in Sub-Saharan Africa. This case series describes an integrated intervention for depression and ART adherence delivered by a lay adherence counselor and supervised by a local psychologist. The 6-session intervention was based on problem-solving therapy for depression and for barriers to adherence (PST-AD), with stepped care for those whose depression did not recover with PST-AD. Primary outcomes were acceptability and depression. Acceptability was measured by participant attendance to the 6 sessions. Three case studies illustrate the structured intervention, solutions identified to adherence barriers and to problems underlying low mood, and changes seen in the clients' psychological symptoms. Acceptability of the intervention was high and common mental disorder symptoms scores measured using the SRQ-8 decreased overall. An integrated intervention for depression and adherence to ART appeared feasible in this low-income setting. An RCT of the intervention versus an appropriate comparison condition is needed to evaluate clinical and cost-effectiveness.

Mutual Capacity Building to Reduce the Behavioral Health Treatment Gap Globally.

Use of lay health workers for the treatment of common mental disorders is an expanding, yet still underutilized, opportunity for closing the behavioral health treatment gap globally. In this commentary, we describe how "mutual capacity building," an equal exchange of ideas between low and middle-income countries (LMICs) and high-income countries (HICs) to promote shared learning, could promote the development and scale-up of therapies using lay health workers. We propose ways that task sharing models for behavioral health can inform and be supported by bidirectional learning across HICs and LMICs.

Biomarker-Measured Unhealthy Alcohol Use in Relation to CD4 Count Among Individuals Starting ART in Sub-Saharan Africa.

Individuals are initiating antiretroviral therapy (ART) at earlier HIV disease stages. Unhealthy alcohol use is a known barrier to successful HIV treatment outcomes, yet it is unclear whether the problem varies by disease stage. We measured alcohol use with an objective biomarker (phosphatidylethanol [PEth]), comparing individuals (n = 401) with early (CD4 > 350 cells/mL, WHO Stage 1) versus late (CD4 < 200 cells/mL) ART initiation in HIV care in Uganda and South Africa (SA). We examined the association between CD4 count and biomarker results using multivariable regression modeling, and compared PEth results to self-report to assess underreporting. Overall, 32.2% (n = 129) had unhealthy alcohol use (PEth ≥ 50 ng/ml). Early ART initiation was significantly associated with unhealthy alcohol use in Uganda (AOR 2.65; 95% CI: 1.05-6.72), but not SA (AOR 1.00; 95% CI: 0.46-2.17). In Uganda, 23.2% underreported unhealthy alcohol use versus 11.6% in SA (χ2 = 9.30; p < 0.01). Addressing unhealthy alcohol use is important as patients initiate ART earlier, yet challenging due to underreporting.