An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial.

Perinatal depression (PND) is common and an important barrier to engagement in HIV care for women living with HIV (WLHIV). Accordingly, we adapted and enhanced The Friendship Bench, an evidence-based counseling intervention, for perinatal WLHIV. In a pilot randomized trial (NCT04143009), we evaluated the feasibility, acceptability, fidelity, and preliminary efficacy of the Enhanced Friendship Bench (EFB) intervention to improve PND and engagement in HIV care outcomes. Eighty pregnant WLHIV who screened positive for PND symptoms on the Self-Report Questionnaire (≥ 8) were enrolled, randomized 1:1 to EFB or usual care, and followed through 6 months postpartum. Overall, 100% of intervention participants were satisfied with the intervention and 93% found it beneficial to their overall health. Of 82 counseling sessions assessed for fidelity, 83% met or exceeded the fidelity threshold. At 6 months postpartum, intervention participants had improved depression remission (59% versus 36%, RD 23%, 95% CI 2%, 45%), retention in HIV care (82% versus 69%, RD 13%, -6%, 32%), and viral suppression (96% versus 90%, RD 7%, -7%, 20%) compared to usual care. Adverse events did not differ by arm. These results suggest that EFB intervention should be evaluated in a fully powered randomized trial to evaluate its efficacy to improve PND and engagement in HIV care outcomes for WLHIV.

HIV Diagnoses, Prevalence and Outcomes in Nine Southern States.

A group of nine states in the Southern United States, hereafter referred to as the targeted states, has experienced particularly high HIV diagnosis and case fatality rates. To provide additional information about the HIV burden in this region, we used CDC HIV surveillance data to examine characteristics of individuals diagnosed with HIV in the targeted states (2011), 5-year HIV and AIDS survival, and deaths among persons living with HIV (2010). We used multivariable analyses to explore the influence of residing in the targeted states at diagnosis on deaths among persons living with HIV after adjustment for demographics and transmission risk. In 2011, the targeted states had a higher HIV diagnosis rate (24.5/100,000 population) than the US overall (18.0/100,000) and higher proportions than other regions of individuals diagnosed with HIV who were black, female, younger, and living in suburban and rural areas. Furthermore, the targeted states had lower HIV and AIDS survival proportions (0.85, 0.73, respectively) than the US overall (0.86, 0.77, respectively) and the highest death rate among persons living with HIV of any US region. Regional differences in demographics and transmission risk did not explain the higher death rate among persons living with HIV in the targeted states indicating that other factors contribute to this disparity. Differences in characteristics and outcomes of individuals with HIV in the targeted states are critical to consider when creating strategies to address HIV in the region, as are other factors identified in previous research to be prominent in the region including poverty and stigma.

Highly stressed: stressful and traumatic experiences among individuals with HIV/AIDS in the Deep South.

A history of traumatic and/or stressful experiences is prevalent among HIV-infected individuals and has been consistently associated with poorer health outcomes. However, little is known about incident stressful experiences and the factors that predict these experiences among HIV-infected individuals. Data from a longitudinal study of 611 HIV-infected individuals in the Southeastern USA were used to examine the frequency and types of incident stress reported in a 27-month period and to determine predictors associated with three incident stress measures (all stressful events, severe stressful events, and traumatic events such as physical assault). Incident stressful experiences frequently occurred among study participants, as 91% reported at least one stressful experience (median=3.5 experiences) and 10% of study participants reported traumatic stress in any given nine-month reporting period. Financial stressors were the most frequently reported by study participants. Greater emotional distress, substance use, and a higher number of baseline stressful experiences were significantly associated with reporting a greater number of incident stressful experiences and any traumatic experiences. Study results indicate that efforts are needed to identify individuals at risk for traumatic events and/or substantial stressors and to address the factors, including mental health and substance abuse, that contribute to these experiences.

Child work and labour among orphaned and abandoned children in five low and middle income countries.

BACKGROUND: The care and protection of the estimated 143,000,000 orphaned and abandoned children (OAC) worldwide is of great importance to global policy makers and child service providers in low and middle income countries (LMICs), yet little is known about rates of child labour among OAC, what child and caregiver characteristics predict child engagement in work and labour, or when such work infers with schooling. This study examines rates and correlates of child labour among OAC and associations of child labour with schooling in a cohort of OAC in 5 LMICs. METHODS: The Positive Outcomes for Orphans (POFO) study employed a two-stage random sampling survey methodology to identify 1480 single and double orphans and children abandoned by both parents ages 6-12 living in family settings in five LMICs: Cambodia, Ethiopia, India, Kenya, and Tanzania. Regression models examined child and caregiver associations with: any work versus no work; and with working <21, 21-27, and 28+ hours during the past week, and child labour (UNICEF definition). RESULTS: The majority of OAC (60.7%) engaged in work during the past week, and of those who worked, 17.8% (10.5% of the total sample) worked 28 or more hours. More than one-fifth (21.9%; 13% of the total sample) met UNICEF's child labour definition. Female OAC and those in good health had increased odds of working. OAC living in rural areas, lower household wealth and caregivers not earning an income were associated with increased child labour. Child labour, but not working fewer than 28 hours per week, was associated with decreased school attendance. CONCLUSIONS: One in seven OAC in this study were reported to be engaged in child labour. Policy makers and social service providers need to pay close attention to the demands being placed on female OAC, particularly in rural areas and poor households with limited income sources. Programs to promote OAC school attendance may need to focus on the needs of families as well as the OAC.

Facilitators, barriers and potential solutions to the integration of depression and non-communicable diseases (NCDs) care in Malawi: a qualitative study with service providers.

BACKGROUND: Integration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional information is required to integrate depression services into chronic disease settings. We assessed service providers' views on the concept of integrating depression care into non-communicable diseases' (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services. METHODS: Between June and August 2018, we conducted nineteen in-depth interviews with providers. Providers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers. RESULTS: Almost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow. CONCLUSION: Findings of this study suggest a need for innovative implementation science solutions such as reorganizing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge. Trial registration This study reports finding of part of the formative phase of "The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building-A Clinic-Randomized Trial of Strategies to Integrate Depression Care in Malawi" registered as NCT03711786.

Incident stressful and traumatic life events and human immunodeficiency virus sexual transmission risk behaviors in a longitudinal, multisite cohort study.

OBJECTIVE: To assess the association between incident stressful life events (e.g., sexual and physical assault; housing instability; and major financial, employment, and legal difficulties) and unprotected anal or vaginal sexual intercourse (unprotected sex) among people living with human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (PLWHA). METHODS: We assessed incident stressful events and unprotected sex over 27 months in 611 participants in an eight-site, five-state study in the Southeast United States. Using mixed-effects logistic models and separately estimating between-person and within-person associations, we assessed the association of incident stressful events with unprotected sex with all partners, HIV-positive partners, and HIV-negative/serostatus-unknown partners. RESULTS: Incident stressful events reported at one third or more of interviews included major illness, injury or accident (non-HIV-related); major illness of a family member/close friend; death of a family member/close friend; financial stresses; and relationship stresses. In multivariable models, each additional moderately stressful event an individual experienced at a given time point above his or her norm (within-person association) was associated with a 24% to 27% increased odds of unprotected sex for each partner type. CONCLUSIONS: Risk reduction among PLWHA remains a major focus of efforts to combat the HIV epidemic. Incident stressful events are exceedingly common in the lives of PLWHA and are associated with increased unprotected sex. Efforts to either prevent the occurrence of such events (e.g., financial or relationship counseling) or address their sequelae (e.g., coping skills or other behavioral counseling) may help reduce secondary HIV transmission.

Physiological and psychosocial factors that predict HIV-related fatigue.

Fatigue is one of the most common and debilitating symptoms experienced by HIV-infected people. We report the results of our longitudinal analysis of physiological and psychosocial factors that were thought to predict changes in HIV-related fatigue in 128 participants over a 1-year period, in an effort to sort out the complex interplay among a comprehensive set of physiological and psychosocial variables. Physiological measures included hepatic function (aspartate aminotransferase, alanine aminotransferase, gamma glutamyl transpeptidase, alkaline phosphatase, total bilirubin, hepatitis C status), thyroid function (thyroid stimulating hormone, thyroxine), HIV viral load, immunologic function (CD4, CD8, CD4/CD8 ratio, CD16, CD8CD38), gonadal function (testosterone, dehydroepiandrosterone), hematologic function (hemoglobin, hematocrit, serum erythropoietin), and cellular injury (lactic acid). Psychosocial measures included childhood and adult trauma, anxiety, depression, social support, stressful life events, and post-traumatic stress disorder (PTSD). Unemployment, not being on antiretroviral therapy, having fewer years since HIV diagnosis, more childhood trauma, more stressful life events, less social support, and more psychological distress (e.g., PTSD, anxiety and depression) put HIV-infected persons at risk for greater fatigue intensity and fatigue-related impairment in functioning during 1-year follow-up. Physiological variables did not predict greater fatigue. Stressful life events had both direct and indirect effects on fatigue.

The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS.

Potent antiretroviral therapy (ART) has transformed HIV from a death sentence to a chronic illness. Accordingly, the goal of HIV care has shifted from delaying death to achieving optimal health outcomes through ART treatment. ART treatment success hinges on medication adherence. Extensive research has demonstrated that the primary barriers to ART adherence include mental illness, especially depression and substance abuse, as well as histories of traumatic experiences such as childhood sexual and physical abuse. These psychosocial factors are highly prevalent in people living with HIV/AIDS (PLWHA) and predict poor ART adherence, increased sexual risk behaviours, ART treatment failure, HIV disease progression and higher mortality rates. The efficacy of standard mental health interventions, such as antidepressant treatment and psychotherapy, has been well-defined, and a small but growing body of research demonstrates the potential for such interventions to improve ART adherence and reduce sexual risk behaviours. Despite this evidence, mental disorders in PLWHA frequently go undiagnosed and untreated. Challenges to the provision of mental healthcare for PLWHA in HIV clinical settings include time and resource constraints, lack of expertise in psychiatric diagnosis and treatment, and lack of available mental health referral services. Future research should prioritize the evaluation of mental health interventions that are cost-effective and feasible for widespread integration into HIV clinical care; the impact of such interventions on ART adherence and clinical outcomes; and interventions to identify individuals with histories of traumatic experiences and to elucidate the mechanisms through which such histories pose barriers to effective HIV treatment.

Overload: impact of incident stressful events on antiretroviral medication adherence and virologic failure in a longitudinal, multisite human immunodeficiency virus cohort study.

OBJECTIVE: To examine the influence of incident stressful experiences on antiretroviral medication adherence and treatment outcomes. Past trauma history predicts poorer medication adherence and health outcomes. Human immunodeficiency virus (HIV)-infected individuals experience frequently traumatic and stressful events, such as sexual and physical assault, housing instability, and major financial, employment, and legal difficulties. METHODS: We measured prospectively incident stressful and traumatic events, medication adherence, and viral load over 27 months in an eight-site, five-state study. Using multivariable logistic and generalized estimating equation modeling, we assessed the impact of incident stressful events on 27-month changes in self-reported medication adherence and virologic failure (viral load = >or=400 c/mL). RESULTS: Of 474 participants on antiretroviral therapy at baseline, 289 persons were interviewed and still received treatment at 27 months. Participants experiencing the median number of incident stressful events (n = 9) had over twice the predicted odds (odds ratio = 2.32) of antiretroviral medication nonadherence at follow-up compared with those with no events. Stressful events also predicted increased odds of virologic failure during follow-up (odds ratio = 1.09 per event). CONCLUSIONS: Incident stressful events are exceedingly common in the lives of HIV-infected individuals and negatively affect antiretroviral medication adherence and treatment outcomes. Interventions to address stress and trauma are needed to improve HIV outcomes.

Prevalence estimation and validation of new instruments in psychiatric research: an application of latent class analysis and sensitivity analysis.

Prevalence and validation studies rely on imperfect reference standard (RS) diagnostic instruments that can bias prevalence and test characteristic estimates. The authors illustrate 2 methods to account for RS misclassification. Latent class analysis (LCA) combines information from multiple imperfect measures of an unmeasurable latent condition to estimate sensitivity (Se) and specificity (Sp) of each measure. With simple algebraic sensitivity analysis (SA), one uses researcher-specified RS misclassification rates to correct prevalence and test characteristic estimates and can succinctly summarize a range of scenarios with Monte Carlo simulation. The authors applied LCA to a validation study of a new substance use disorder (SUD) screener and a larger prevalence study. With a traditional validation study analysis in which an error-free RS (Structured Clinical Interview for DSM-IV Axis I Disorders [SCID]; M. H. First, R. L. Spitzer, M. Gibbon, & J. Williams, 1990) is assumed, the authors estimated the screener had 86% Se and 75% Sp. Validation study estimates from LCA were 91% Se, 81% Sp (screener), 73% Se, and 98% Sp (SCID). SA in the prevalence study suggested the prevalence of SUD was underestimated by 22% because SCID was assumed to be error-free. LCA and SA can assist investigators in relaxing the unrealistic assumption of perfect RSs in reporting prevalence and validation study results.

The Sub-Saharan Africa Regional Partnership (SHARP) for Mental Health Capacity Building: a program protocol for building implementation science and mental health research and policymaking capacity in Malawi and Tanzania.

BACKGROUND: Mental health (MH) disorders in low and middle-income countries (LMICs) account for a large proportion of disease burden. While efficacious treatments exist, only 10% of those in need are able to access care. This treatment gap is fueled by structural determinants including inadequate resource allocation and prioritization, both rooted in a lack of research and policy capacity. The goal of the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP), based in Malawi and Tanzania, is to address those research and policy-based determinants. METHODS: SHARP aims to (1) build implementation science skills and expertise among Malawian and Tanzanian researchers in the area of mental health; (2) ensure that Malawian and Tanzanian policymakers and providers have the knowledge and skills to effectively apply research findings on evidence-based mental health programs to routine practice; and (3) strengthen dialogue between researchers, policymakers, and providers leading to efficient and sustainable scale-up of mental health services in Malawi and Tanzania. SHARP comprises five capacity building components: introductory and advanced short courses, a multifaceted dialogue, on-the-job training, pilot grants, and "mentor the mentors" courses. DISCUSSION: Program evaluation includes measuring dose delivered and received, participant knowledge and satisfaction, as well as academic output (e.g., conference posters or presentations, manuscript submissions, grant applications). The SHARP Capacity Building Program aims to make a meaningful contribution in pursuit of a model of capacity building that could be replicated in other LMICs. If impactful, the SHARP Capacity Building Program could increase the knowledge, skills, and mentorship capabilities of researchers, policymakers, and providers regarding effective scale up of evidence-based MH treatment.

Prevalence and comorbidity of psychiatric diagnoses based on reference standard in an HIV+ patient population.

OBJECTIVE: To study the prevalence of psychiatric comorbidity based on reference standard diagnostic criteria in patients with human immunodeficiency virus (HIV). Psychiatric illness is common in patients with HIV and has been associated with negative health behaviors and poorer clinical outcomes. Among those persons with psychiatric illness, psychiatric comorbidity (multiple simultaneous diagnoses) is associated with increased psychiatric severity and higher HIV risk behaviors. METHODS: A total of 152 consecutively presenting HIV+ patients at an academic medical center in the southeastern US completed a modified Structured Clinical Interview for DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4(th) Edition) that assessed mood, anxiety, and substance use disorders in the past year and past month. RESULTS: Fifty percent and 33% of patients had a past-year and past-month diagnosis, respectively. The most common diagnoses were mood disorders (32% past year/21% past month) followed by anxiety (21%/17%) and substance use disorders (22%/11%). Half of those with past-year disorders and 40% of those with past-month disorders met the criteria for multiple diagnoses. Of those with a mood disorder in the past month, 53% also had an anxiety or substance use disorder; of those with an anxiety disorder, 62% also had a mood or substance use disorder; and of those with a substance use disorder, 63% also had a mood or anxiety disorder. Psychiatric comorbidity was associated with younger age, White non-Hispanic race/ethnicity, and greater HIV symptomatology. CONCLUSIONS: Comorbidity of mood, anxiety, and substance use disorders was the exception rather than the rule in this sample. Potential co-occurring disorders should be considered for HIV+ patients presenting with a psychiatric diagnosis.

Trends in HIV testing and differences between planned and actual testing in the United States, 2000-2005.

BACKGROUND: Increasing the rates of human immunodeficiency virus (HIV) testing among groups not traditionally perceived as being at high risk has been advanced as a primary strategy in the effort to combat the HIV epidemic. METHODS: We conducted a pooled cross-sectional analysis of data from 146 868 participants aged 18 to 64 years in the 2000-2005 National Health Interview Surveys to describe longitudinal trends in HIV testing rates in the US population and differences between planned and actual testing across demographic and risk groups. Multivariable logistic models were estimated to assess correlates of perceived risk for HIV infection and planned and actual HIV testing. Difference-in-differences models examine how differences between planned and actual testing varied with demographic characteristics, perceived risk, alcohol consumption, depression, and health behaviors and access. RESULTS: Rates of HIV testing remained relatively unchanged from 2000 to 2005 (mean rates for lifetime and past year, 37% and 10%, respectively) and varied substantially by sex and race, with female and minority (nonwhite) populations more likely to get tested. Rates were higher in individuals reporting greater risks of HIV infection. However, even among respondents reporting medium or high risks of contracting HIV, less than 25% reported an HIV test in the previous year. Those with a higher perceived risk, more alcohol consumption, and more depressive symptoms had higher rates of both planned and actual testing but also demonstrated the greatest deficit of actual relative to planned testing. CONCLUSIONS: In the United States, HIV testing rates remain low, nationally and in high-risk populations; low rates are likely contributing to a substantial number of undiagnosed cases of HIV. Despite above-average testing rates, populations considered to be at increased risk for HIV infection still demonstrate the need for improved access to and utilization of testing.

Demographic and illness-related variables associated with HIV-related fatigue.

Fatigue is one of the most debilitating symptoms suffered by those with HIV infection, yet little is known about its correlates. The primary aims of this study were to describe the degree to which fatigue affects daily functioning and the demographic and illness-related predictors of fatigue. The sample (n = 128) was composed of primarily poor, unemployed people of color. Fatigue most often interfered with the ability to think quickly, perform household chores, exercise, work, engage in recreational activities, walk, plan activities, and think clearly. The consequences of fatigue were highest for lowered motivation, difficulty concentrating, increased drowsiness, losing patience, and interference with work, family, and social life. Multiple linear regression analyses showed statistically significant associations of employment status, monthly income, current antidepressant use, and number of years living with HIV infection as predictors of fatigue. These must be better understood to develop interventions to successfully ameliorate HIV-related fatigue.

Physiological correlates of HIV-related fatigue.

Our primary aim is to describe the relationship of multiple physiological variables and HIV-related fatigue. We report baseline data collected from 128 human immunodeficiency virus (HIV)-positive individuals. The HIV-Related Fatigue Scale was used to measure several aspects of fatigue. Blood was drawn for the following physiological variables: hepatic function, thyroid function, HIV viral load, immunologic function, gonadal function, hematologic function, serum cortisol, and cellular injury. In bivariable analyses, free testosterone (p=0.03) and CD8 (p=0.07) were negatively correlated with fatigue intensity, and nonlinear relationships were observed between fatigue intensity and total testosterone (p=0.02), thyroxine (p=0.01), hematocrit (p=0.06), and total bilirubin (p=0.06). However, none of these associations persisted in multivariable models. It is possible that fatigue suffered by seropositive people is better predicted by other variables, which must be better understood to develop interventions to successfully ameliorate HIV-related fatigue.

Relation of lifetime trauma and depressive symptoms to mortality in HIV.

OBJECTIVE: In an era of highly active antiretroviral therapies, the authors needed to confirm previous findings showing that stress and depression have an impact on HIV disease progression. The goal of the current study was to examine the effects of lifetime trauma, recent stressful events, and depression on all-cause and AIDS-related mortality among HIV-infected men and women. The authors hypothesized that these psychosocial variables would predict significantly faster HIV-specific and all-cause mortality. METHOD: The authors consecutively sampled HIV-infected men and women who received care at one of eight infectious diseases clinics in five Southeastern states. The sample included 490 patients who were followed by interview for 27 months and followed with their medical records for up to 41 months. RESULTS: There were 29 deaths; 16 were AIDS-related. More lifetime trauma and antigenic marker on helper/inducer T cells (CD4)<200 significantly predicted faster all-cause and AIDS-related mortality. For those at or above the median in trauma, the all-cause death rate was 3.54 per 100 person-years, compared to 1.72 for those below the median. For those at or above the median in trauma, the AIDS-related death rate was 2.13 per 100 person-years, compared to 0.77 for those below the median. Depressive symptoms and higher baseline viral load were significantly related to greater risk of AIDS-related mortality. CONCLUSIONS: Further research is needed to determine if interventions to address trauma and depression can modify these detrimental effects on HIV.

Predictors of AIDS-related morbidity and mortality in a southern U.S. Cohort.

Advances in the treatment of HIV and associated opportunistic infections (OIs) have led to dramatic reductions in HIV-related morbidity and mortality in the United States, but not all patients have benefited equally. A longitudinal analysis of the Coping with HIV/AIDS in the Southeast (CHASE) cohort evaluated sociodemographic, psychosocial, and clinical factors associated with HIV-related events (incident category C OI or AIDS-related death) among southern HIV-infected patients engaged in clinical care. Participants were followed for a median of 30 months (interquartile range, 17-34 months) after study enrollment (enrollment period December 2001 to April 2002). Ten percent of study participants (50/489) experienced an HIV-related event (incident category C OI and/or AIDS-related deaths) during study follow-up. The rate of HIV-related events was 4.8 per 100 patient-years of observation, and the rate of AIDS-related death was 1.5 per 100 patient-years of observation. In unadjusted survival analyses, younger age, lacking private health insurance, psychosocial trauma, depressive symptoms, lower baseline CD4 count, and less time on antiretroviral therapy during follow-up were associated with HIV-related events. In Cox proportional hazards analysis adjusting for covariates, patients who had suffered more psychosocial trauma (hazard ratio [HR] = 1.97, p = 0.04), who had lower baseline CD4 counts (HR = 0.48 per 100 cells/mm(3), p < 0.01), and who spent less time on antiretroviral therapy during follow-up (HR = 0.47, p = 0.02) were more likely to experience an HIV-related event.

Predicting adolescents' longitudinal risk for sexually transmitted infection: results from the National Longitudinal Study of Adolescent Health.

BACKGROUND: Influencing adolescents' sexual behaviors has the potential to influence trajectories of risk for sexually transmitted infections (STIs) among young adults. OBJECTIVE: To determine whether family, school, and individual factors associated with increased duration of virginity also protect against STIs in young adulthood. DESIGN: Prospective cohort study. Wave I of the National Longitudinal Study of Adolescent Health occurred in 1995 when participants were in grades 7 through 12. Six years later, all wave I participants who could be located were invited to participate in wave III and provide a urine specimen for STI testing. SETTING: In-home interviews in the continental United States, Alaska, and Hawaii. PARTICIPANTS: Population-based sample. Of 18,924 participants in the nationally representative weighted wave I sample, 14,322 (75.7%) were located and participated in wave III. Test results for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis were available for 11,594 (81.0%) of wave III participants. MAIN OUTCOME MEASURE: Positive test result for C. trachomatis, N. gonorrhoeae, or T. vaginalis. RESULTS: Controlling for biological sex, age, race/ethnicity, family structure, and maternal education, adolescents who perceived that their parents more strongly disapproved of their having sex during adolescence were less likely to have STIs 6 years later (adjusted odds ratio, 0.89; 95% confidence interval, 0.81-0.99). Those with a higher grade point average during adolescence were also less likely to acquire STIs (adjusted odds ratio, 0.84; 95% confidence interval, 0.71-0.99). Stratified analyses confirmed these findings among female, but not male, adolescents. Feelings of connection to family or school, reported importance of religion, attending a parochial school, and pledges of virginity during adolescence did not predict STI status 6 years later. CONCLUSIONS: Perceived parental disapproval of sexual intercourse and higher grades in school during adolescence have protective influences on the trajectory of risk for acquiring STIs, primarily among female adolescents. Most factors associated with increased duration of virginity in adolescence do not influence the trajectory of STI risk.

Sexual health experiences of adolescents in three Ghanaian towns.

CONTEXT: Ghanaian youth are greatly affected by widespread social change, and their reproductive health needs may differ by social group, age and gender. METHODS: In-person interviews on sexual health issues were conducted with 704 never-married youth aged 12-24 in three Ghanaian towns. The sample included youth who were in school, in apprenticeship programs or in neither school nor apprenticeship programs (unaffiliated). RESULTS: More than half of the respondents had ever had sexual intercourse (52%), with the adjusted odds for females being 1.6 times those for males and the odds for unaffiliated and apprenticed youth being 2.5-3.2 times those for in-school youth. The odds of having had sex in the previous month were elevated for females (2.0) and apprentices (2.7). Both sexes tended to accept violence towards women, with unaffiliated youth showing the highest level of acceptance and in-school youth the lowest. Nearly all respondents (99%) knew of condoms, but fewer than half (48%) could identify any of four elements of correct use; females and sexually inexperienced youth were the least informed. Two-thirds of respondents considered it unacceptable for males to carry condoms, and three-quarters considered it unacceptable for females. Twenty-five percent of males and 8% of females reported having had a sexually transmitted infection. One-third of sexually experienced females reported having ever been pregnant; of those, 70% reported having had or having attempted to have an abortion. CONCLUSIONS: Adolescent reproductive health programs should be targeted to the needs of specific groups.

Intensity, chronicity, circumstances, and consequences of HIV-related fatigue: a longitudinal study.

HIV-related fatigue remains the most troubling complaint of seropositive people. Researchers often use tools to measure fatigue that were developed for other patient populations; thus, the measurement of fatigue specific to HIV is needed. This article describes results from the HIV-Related Fatigue Scale (HRFS) including: (a) the variability in intensity and chronicity of HIV-related fatigue, (b) the circumstances surrounding changes in fatigue, (c) the impact of fatigue on activities of daily living (ADLs), and (d) the consequences of HIV-related fatigue. We collected data every 3 months over a 3-year period from 128 people. HIV-related fatigue was chronic and did not appear to remit spontaneously; those who were the most fatigued at the beginning of the study remained the most fatigued over 3 years. Fatigue interfered more with instrumental activities of daily living than basic ADLs; it also interfered with work, family, and social life. Stress and depression increased fatigue.