Impact of COVID-19 on Adolescent HIV Prevention and Treatment Research in the AHISA Network.

Members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) network conduct research aiming to close gaps between what is known to be impactful across the HIV prevention and treatment cascade, and services delivered to optimize outcomes for adolescents/young adults (AYA) in high HIV-prevalence settings. The COVID-19 pandemic introduced new challenges which threaten to exacerbate care and access disparities. We report results of a survey among AHISA teams with active AYA HIV research programs in African countries to determine how the pandemic has impacted their efforts. Results highlighted the detrimental impact of the pandemic on research efforts and the expanded need for implementation research to help provide evidence-based, context-specific pandemic recovery support. Key lessons learned included the viability of remote service delivery strategies and other innovations, the need for adaptive systems that respond to evolving contextual needs, and the need for organized documentation plans, within empathic and flexible environments.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network.

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

Youth perspectives of working with near peer youth lay counsellors: The Safe Haven Pilot.

Youth living with HIV (YLWH) have higher rates of common mental disorders (CMDs) when compared with HIV-negative youth. We adapted the Friendship Bench to create a problem solving-based counselling intervention in Botswana delivered by near peer youth lay counsellors for YLWH called Safe Haven. In August 2020, and from June to August 2021, we conducted 22 semistructured interviews with youth aged 13-25 years with mild-to-moderate symptoms of CMDs. Two independent coders carried out an inductive thematic analysis of the transcribed interviews with discrepancies discussed to consensus. Safe Haven was seen as largely acceptable among the youth. Youth felt Safe Haven was a place where they had freedom of expression and could receive practical advice from well-trained and approachable counsellors. Trained youth lay peer counsellors show promise to meet the mental health needs of mild and moderately symptomatic youth, where mental health professionals are in short supply.

Roles and responsibilities of expert clients in adolescent HIV service delivery in Eswatini: a conventional content analysis.

We aimed to elucidate the specific roles and responsibilities of expert clients in service delivery among adolescents living with HIV in Eswatini, and to provide recommendations for enhancing adolescent service provision among expert clients and similar lay health workers throughout low- and middle-income countries. An exploratory qualitative descriptive methodology using conventional content analysis was used to meet our study aims. We recruited 20 expert clients and 12 key informants (programme managers, programme coordinators and nurses) to participate in semi-structured interviews, and we arranged four focus group discussions among adolescents living with HIV with seven to ten participants per focus group. Adherence counselling in clinical and community settings was considered paramount to the roles and responsibilities of expert clients with regard to adolescent-specific HIV service delivery. The following recommendations were made to enhance expert client service delivery practices among adolescents: (1) training in adolescent developmental, sexual and reproductive needs; (2) training to enhance clinical knowledge and skills; (3) additional work equipment and compensation; and d) more parent and guardian engagement in their work. While expert clients meet the needs of adolescents living with HIV in several capacities, they require additional resources, skills and training to improve their work, especially in the realm of sexual and reproductive health. Future research is needed to evaluate the impact of expert client service delivery on adolescent health outcomes.

Results from Project GOLD: A pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention for black youth.

Black youth face significant disparities in HIV/sexually transmitted infection (STI) disease burden. Mental illness and emotion regulation are ontributors to HIV/STI risk, yet many HIV/STI prevention interventions do not address these factors. Project GOLD was a pilot randomized controlled trial of a psychoeducational HIV/STI prevention intervention designed to address the role of mental illness and emotion regulation in HIV/STI risk among heterosexually active Black youth aged 14-17 (N = 108). Participants were recruited from outpatient mental health treatment programs and general community settings via community partner referrals, face-to-face encounters, flyers and social media. Assessments were conducted pretest, immediate posttest, and at 3-, 6-, and 12-month follow-up. Although there were no statistically significant differences in behavior change from baseline, there were practically significant effect sizes among HIV condition participants when compared to the general health condition (e.g., fewer sexual partners at 6 months). An increase in theoretical mediators (e.g., condom use negotiation beliefs) was sustained at 12 months. HIV condition participants also reported lower depressive symptom severity, with statistical significance noted at immediate post and at 3 months. The findings highlight the importance and challenges of engaging Black youth in culturally and contextually relevant, developmentally and psychologically appropriate HIV/STI prevention interventions.

Experiences of Hospitalization of Patients With Psychotic Disorders on Medical-Surgical Units: A Thematic Analysis.

BACKGROUND:Individuals with psychotic disorders are more likely to have nonpsychiatric hospitalizations than the general population. Moreover, they experience worse outcomes in terms of rehospitalization, adverse events, in-hospital mortality, and longer length of stay. AIM: A patient-centered understanding of inpatient medical-surgical hospitalization experiences could shed light on disparities in hospital outcomes among individuals with psychotic disorders. METHOD: This article reports findings from Phase 1 (Qualitative) of a mixed methods, exploratory sequential study of nonpsychiatric hospitalizations of patients with psychotic disorders. Patients on medical-surgical units with diagnosed psychotic disorders (n = 20) were interviewed about their experiences of hospitalization, and a thematic analysis was conducted of transcripts, case notes, and setting notes. RESULTS: Five themes emerged from analysis: (1) managing through hard times (subthemes: intense emotions, medically complex with many symptoms, strategies for self-management), (2) ignored and treated unfairly, (3) actively involved in health (subthemes: seeking health education, suggesting changes), (4) appreciation of caring providers, and (5) violence: expected and enacted. Participants connected the difficult nature of their hospitalization experiences with a variety of sources and outcomes, including strong emotions, variable relationships with providers and a struggle to receive health education. CONCLUSIONS: Nurses who care for patients with psychotic disorders in medical-surgical settings can better meet patients' needs by concentrating on relationship building, especially during initial interactions, and helping patients better manage their medical and psychiatric symptoms through both pharmaceutical and nursing interventions.

Expansion of Treatment for Hepatitis C Virus Infection by Task Shifting to Community-Based Nonspecialist Providers: A Nonrandomized Clinical Trial.

Background: Direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection has resulted in high rates of disease cure; however, not enough specialists currently are available to provide care. Objective: To determine the efficacy of HCV treatment independently provided by nurse practitioners (NPs), primary care physicians (PCPs), or specialist physicians using DAA therapy. Design: Nonrandomized, open-label clinical trial initiated in 2015. (ClinicalTrials.gov: NCT02339038). Setting: 13 urban, federally qualified health centers (FQHCs) in the District of Columbia. Patients: A referred sample of 600 patients, of whom 96% were black, 69% were male, 82% were treatment naive, and 20% had cirrhosis. Seventy-two percent of the patients had HCV genotype 1a infection. The baseline characteristics of patients seen by each provider type were similar. Intervention: Patients were assigned in a nonrandomized but specified manner to receive treatment from 1 of 5 NPs, 5 PCPs, or 6 specialists. All providers underwent an identical 3-hour training session based on guidelines. Patients received treatment with ledipasvir-sofosbuvir, which was provided on site, according to U.S. Food and Drug Administration labeling requirements. Measurements: Sustained virologic response (SVR). Results: 516 patients achieved SVR, a response rate of 86% (95% CI, 83.0% to 88.7%), with no major safety signals. Response rates were consistent across the 3 provider types: NPs, 89.3% (CI, 83.3% to 93.8%); PCPs, 86.9% (CI, 80.6% to 91.7%); and specialists, 83.8% (CI, 79.0% to 87.8%). Patient loss to follow-up was the major cause of non-SVR. Limitation: Nonrandomized patient distribution; possible referral bias. Conclusion: In a real-world cohort of patients at urban FQHCs, HCV treatment administered by nonspecialist providers was as safe and effective as that provided by specialists. Nurse practitioners and PCPs with compact didactic training could substantially expand the availability of community-based providers to escalate HCV therapy, bridging existing gaps in the continuum of care for patients with HCV infection. Primary Funding Source: National Institutes of Health and Gilead Sciences.

Barriers to antiretroviral therapy initiation for HIV-positive children aged 2-18 months in Swaziland.

Although early antiretroviral therapy (ART) reduces HIV-related mortality in children by up to 75%, almost half of HIV-positive children younger than 1 year old in Swaziland do not initiate ART. This study was conducted to identify barriers to early ART initiation among HIV-positive infants. This was a case-control study among HIV-positive infants, aged 2 to 18 months, who either did not initiate ART (cases), or initiated ART (controls), during 18 months after testing. Multivariable logistic regression showed that infants who visited the clinic every month, or every 2 months, were 5.78 and 6.20 times more likely to initiate ART than those who visited less often (OR 5.78, 95% CI 1.82-18.33 and OR 6.20, 95% CI 1.30-29.60 respectively). Children who lived ≤30 and 31-60 minutes from the nearest clinic were 84% and 79% less likely respectively to initiate ART (OR 0.16, 95% CI 0.03-0.78 and OR 0.21, 95% CI 0.04-0.98) compared with those who lived more than 60 minutes away. Children who received immunisation after 6 months were 22.59 times more likely to initiate ART (OR 22.59, 95% CI 7.00-21.72) than those who did not. Infants of caregivers who had excellent or good relationships with their healthcare provider were 4.32 times more likely to initiate ART (OR 4.32, 95% CI 1.01-18.59) than those of caregivers who had average or poor relationships with healthcare providers. The significant predictors of ART initiation identified in this study should be regarded as priority areas for intervention among HIV-positive women in Swaziland.

A qualitative analysis of the barriers to antiretroviral therapy initiation among children 2 to 18 months of age in Swaziland.

HIV/AIDS remains one of the leading causes of death among children under 5 years old in Swaziland. Although studies have shown that early initiation of infants and children diagnosed with HIV on antiretroviral therapy (ART) significantly reduces mortality, many children do not initiate ART until the later stages of disease. This study was designed to collect qualitative data from mothers and caregivers of HIV-positive children to identify the barriers to ART initiation. Focus group discussion (FGD) sessions were conducted in siSwati between July and September 2014 among caregivers of aged children 2-18 months in Swaziland who did or did not initiate ART between January 2011 and December 2012 after HIV DNA PCR-positive diagnosis of the infants. Denial, guilt, lack of knowledge, tuberculosis (TB)/HIV co-infection, HIV-related stigma, lack of money, and distance to clinics were reported by the participants as barriers to ART initiation. The findings further revealed that non-initiation on ART was not linked to a negative perception of the treatment. Findings suggest a need to improve sensitivity among healthcare workers as well as education and counselling services that will facilitate the ART initiation process.

Parental Legal System Involvement, Positive Childhood Experiences, and Suicide Risk.

OBJECTIVES: To examine whether adverse parental legal system involvement (incarceration, arrest) was associated with suicide risk, accounting for other adverse childhood experiences, and whether there was a moderating relationship between positive childhood experiences (PCEs) and parental legal system involvement in suicide risk. METHODS: This cross-sectional study used 2-year follow-up data from the Adolescent Brain Cognitive Development Study when children were age 11 to 12 years. Outcomes were lifetime suicidal ideation, attempts, and nonsuicidal self-injury (NSSI). Exposures were parent incarceration or arrest. We used generalized linear models to estimate the relative risk of suicide outcomes from adverse parent legal involvement and whether there was an interaction between parent legal system involvement and PCE count, controlling for adverse childhood experiences and demographic factors. RESULTS: Among our sample (n = 10 532;), 687 children (6.5%) reported parent incarceration and 1265 (12.0%) reported parent arrest. Suicidal ideation was the most frequent risk outcome (n = 490; 4.7%). Children whose parents had been incarcerated had a relative risk of suicidal ideation of 1.74 (95% CI: 1.32-2.31). Children whose parents had been arrested had a relative risk of suicidal ideation of 1.89 (95% CI: 1.53-2.37) and a relative risk of suicide attempt of 2.69 (95% CI: 1.7-4.25). Parental incarceration/arrest were not associated with NSSI. PCEs were associated with reduced relative risk of suicidal ideation and NSSI, though there was no significant interaction between PCEs and adverse parent legal system involvement exposures. CONCLUSIONS: Parental legal system involvement may negatively affect child mental health. Strengthening PCEs in childhood may mitigate suicide-related risks.

The NUDGE Framework: Application to Address Behavioral Barriers to Antiretroviral Therapy in Adolescents Living With HIV in Eswatini.

Behavioral economics offers a unique opportunity to understand the social, cognitive, and psychological nuances that may influence health behavior. The purpose of this article is to demonstrate the application of NUDGE, a novel behavioral economics and design thinking framework, to address barriers to antiretroviral therapy adherence among adolescents living with HIV in eSwatini. NUDGE comprises five steps: (1) Narrow the focus to a specific target behavior, (2) Understand the context of the behavior through inquiry, (3) Discover behavioral insights related to the target behavior, (4) Generate intervention design features to address behavioral barriers to the target behavior, and (5) Evaluate the design features through iterative pilot testing. This article demonstrates the application of the Discover and Generate steps using qualitative data. In showing the utility of the NUDGE framework, we provide a practical tool for creating interventions informed by behavioral insights.

Addressing Social Context in Adverse Childhood Experience Screening Policy: Implications for Children With Special Health Care Needs.

Adverse childhood experiences (ACEs) disproportionately affect children with special health care needs, especially racial and ethnic minority children whose ACEs may be less likely to be identified. As awareness and understanding of the health impacts of ACEs have increased, heightened by the COVID-19 pandemic, several areas of the United States have initiated policy efforts to screen for and address ACEs. However, these policies do not always include mechanisms to account for context-specific adversity or contemporary stressors in the lives of children. Stressors most significant in a child's life may include adversities beyond those included in common ACE screening instruments. ACE policy in California will be discussed relative to addressing the social context in ACEs screening. By taking a holistic view of ACEs and thinking beyond deriving ACE scores alone, clinicians can ensure that ACE-related policies are implemented with maximum benefit to diverse children with special health care needs.

A Systematic Review of Peer Support Interventions for Adolescents Living with HIV in Sub-Saharan Africa.

Despite widespread availability of life-saving antiretroviral therapy (ART) in sub-Saharan Africa, AIDS remains one of the leading causes of death among adolescents living with HIV (ALHIV) in sub-Saharan Africa. The purpose of this article was to review the state of the science regarding interventions to improve ART adherence and/or HIV care retention among ALHIV throughout sub-Saharan Africa. The primary aim of this review was to describe the impact of peer support interventions in improving treatment outcomes (i.e., ART adherence and retention in HIV care) among ALHIV in sub-Saharan Africa. The secondary aim of this review was to determine whether these interventions may be efficacious at improving mental health outcomes. We identified 27 articles that met the eligibility criteria for our review, and categorized each article based on the type of peer support provided to ALHIV-individualized peer support, group-based support, and individualized plus group-based support. Results regarding the efficacy of these interventions are mixed and most of the studies included were deemed moderate in methodological quality. Although studies evaluating group-based peer support interventions were the most common, most of these studies were not associated with retention, adherence, or mental health outcomes. More robust, fully powered studies are needed to strengthen our knowledge base regarding peer support for ALHIV.

A qualitative analysis of the barriers to antiretroviral therapy initiation among children 2 to 18 months of age in Swaziland

HIV/AIDS remains one of the leading causes of death among children under 5 years old in Swaziland. Although studies have shown that early initiation of infants and children diagnosed with HIV on antiretroviral therapy (ART) significantly reduces mortality, many children do not initiate ART until the later stages of disease. This study was designed to collect qualitative data from mothers and caregivers of HIV-positive children to identify the barriers to ART initiation. Focus group discussion (FGD) sessions were conducted in siSwati between July and September 2014 among caregivers of aged children 2­18 months in Swaziland who did or did not initiate ART between January 2011 and December 2012 after HIV DNA PCR-positive diagnosis of the infants. Denial, guilt, lack of knowledge, tuberculosis (TB)/HIV co-infection, HIV-related stigma, lack of money, and distance to clinics were reported by the participants as barriers to ART initiation. The findings further revealed that non-initiation on ART was not linked to a negative perception of the treatment. Findings suggest a need to improve sensitivity among healthcare workers as well as education and counselling services that will facilitate the ART initiation process