Leveraging Bluetooth low-energy technology to improve contact tracing among healthcare personnel in hospital setting during the coronavirus disease 2019 (COVID-19) pandemic.

To improve contact tracing for healthcare workers, we built and configured a Bluetooth low-energy system. We predicted close contacts with great accuracy and provided an additional contact yield of 14.8%. This system would decrease the effective reproduction number by 56% and would unnecessarily quarantine 0.74% of employees weekly.

The relationship between life satisfaction, personal health, quality of life, and medication adherence among adolescents living with HIV in southwestern Uganda.

Purpose: Adolescents living with HIV (ALHIV) are at high risk for adherence to antiretroviral (ART) treatment and poor health-seeking behaviors, both of which potentially compromise their quality of and satisfaction with life. This study, therefore, seeks to examine the relationship between physical health, pediatric quality of life, life satisfaction, and medication adherence among ALHIV in southwestern Uganda. Methods: Baseline data from the Suubi+Adherence study, 2012-2018, that recruited 702 adolescents, aged 10-16 years, living with HIV in Uganda were analyzed. To account for overdispersion, negative binomial regression analyses were used to examine the impact of physical health, pediatric quality of life, and life satisfaction on self-reported medication adherence. We controlled for participants' socio-demographic factors. Results: Results indicated that after adjusting for socio-demographic characteristics, adolescents' reported satisfaction with life was associated with a decrease in the reported number of days missed taking medication by 41.2% (IRR (incidence risk ratio)=0.588; p (p-value)=0.014). On the other hand, the low level of pediatric quality of life was associated with a 5% increase in the reported number of days missed taking medication (IRR=1.055, p=0.044). Personal health was not statistically significant in the model. Conclusion: Our study findings indicated that quality of life and life satisfaction are significantly associated with antiretroviral (ART) medication among ALHIV. Hence, strengthening existing support systems and creating additional support for optimal ART adherence and treatment outcomes for ALHIV in low-resource communities might be beneficial. Moreover, with the increasing HIV prevalence rates among adolescents, effective and comprehensive efforts that are responsive to the special needs of ALHIV must be developed to ensure optimal adherence to ART medication as it leads to low vertical infection and superinfection rates.

Addition of aminoglycosides reduces recurrence of infections with multidrug-resistant Gram-negative bacilli in patients with sepsis and septic shock.

OBJECTIVES: Aminoglycosides and ß-lactams have been recommended for treatment of sepsis/septic shock despite a lack of mortality benefit. Previous studies have examined resistance emergence for the same bacterial isolate using old dosing regimens and during a narrow follow-up window. We hypothesised that combination regimens employing aminoglycosides will decrease the cumulative incidence of infections due to multidrug-resistant (MDR) Gram-negative bacilli (GNB) compared with ß-lactams alone. METHODS: All adult patients admitted to Barnes Jewish Hospital between 2010 and 2017 with a diagnosis of sepsis/septic shock were included in this retrospective cohort study. Patients were divided into two treatment groups, with and without aminoglycosides. Patient demographics, severity of presentation, administered antibiotics, follow-up cultures with susceptibility results for a period of 4-60 days, and mortality were extracted. After propensity score matching, a Fine-Gray subdistribution proportional hazards model summarised the estimated incidence of subsequent infections with MDR-GNB in the presence of all-cause death as a competing risk. RESULTS: A total of 10 212 septic patients were included, with 1996 (19.5%) treated with at least two antimicrobials including one aminoglycoside. After propensity score matching, the cumulative incidence of MDR-GNB infections between 4-60 days was lower in the combination group (incidence at 60 days 0.073, 95% CI 0.062-0.085) versus patients not receiving aminoglycosides (0.116, 95% CI 0.102-0.130). Patients aged ≤65 years and with haematological malignancies had a larger treatment effect in subgroup analyses. CONCLUSION: Addition of aminoglycosides to ß-lactams may protect against subsequent infections due to MDR-GNB in patients with sepsis/septic shock.

The Relationship Between Family Cohesion and Depression Among School-Going Children With Elevated Symptoms of Behavioral Challenges in Southern Uganda.

PURPOSE: Depression is among the leading causes of disability and contributes significantly to the overall disease burden affecting children. Family cohesion has been identified as a protective factor against depression. Examining this relationship is necessary in sub-Saharan Africa, specifically in Uganda-a country characterized by a high prevalence of HIV/AIDS, and high rates of chronic poverty, all of which stress family functioning and elevate child behavioral challenges. This study examined the relationship between family cohesion and depression among school-going children with elevated symptoms of behavioral challenges in southern Uganda. METHODS: At baseline, 2089 children were enrolled in the National Institutes of Health-funded Strengthening Mental Health and Research Training Africa study in Southwestern Uganda. This article analyzed data from 626 children aged 8-13 years with elevated behavioral challenges. We conducted multilevel mixed-effects Poisson regression to determine the association between family cohesion and depression. We controlled for sociodemographic and household characteristics. RESULTS: The mean age was 10.3 years. The overall mean depression score was 3.2 (standard deviation = 2.7, range = 0-15). Family cohesion (ß = -0.03, 95% confidence interval [CI]: -0.04, -0.02, p < .001) and owning essential items by the child (ß = -0.13, 95% CI: -0.23, -0.04, p = .005) were protective against depression among children. Additionally, we observed being a single orphan (ß = -0.44, 95% CI: -0.03, -0.86, p = .036) and having both parents (ß = -0.43, 95% CI: -0.06, -0.81, p = .023) were associated with depression among children. DISCUSSION: Findings from this study reveal that family cohesion was protective against depression. Therefore, it is vital to strengthen family support systems by developing programs aimed at strengthening family relationships as a catalyst for addressing depression among children.

A Structural Equation Model of the Impact of a Family-Based Economic Intervention on Antiretroviral Therapy Adherence Among Adolescents Living With HIV in Uganda.

PURPOSE: Antiretroviral therapy (ART) adherence among adolescents living with HIV (ALWHIV) is low, with poverty remaining a significant contributor. We examined the mediation pathways between an economic empowerment intervention and ART adherence among ALWHIV. METHODS: This cluster-randomized controlled trial (2012-2018) recruited 702 ALWHIV aged 10-16 in Uganda between January 2014 and December 2015. We randomized 39 clinics into the control (n = 344) or intervention group (n = 358). The intervention comprised a child development account, four microenterprise workshops, and 12 mentorship sessions. We used six self-reported items to measure adherence at 24 months, 36 months, and 48 months. We used structural equation modeling to assess the mediation effects through mental health and adherence self-efficacy, on adherence. We ran models corresponding to the 24, 36, and 48 months of follow-up. RESULTS: The mean age of the participants was 12 years, and 56% were female. At 36 (model 2) and 48 months (model 3), the intervention had a significant indirect effect on ART adherence [B = 0.069, ß = 0.039 (95% confidence interval [CI]: 0.005-0.074)], and [B = 0.068, ß = 0.040 (95% CI: 0.010-0.116)], respectively. In both models, there was a specific mediation effect through mental health [B = 0.070, ß = 0.040 (95% CI: 0.007-0.063)], and [B = 0.039, ß = 0.040 (95% CI: 0.020-0.117)]. Overall, 49.1%, 90.7%, and 36.8% of the total effects were mediated in models, 1, 2, and 3, respectively. DISCUSSION: EE interventions improve adherence, by improving mental health functioning. These findings warrant the need to incorporate components that address mental health challenges in programs targeting poverty to improve ART adherence in low-income settings.

Self-efficacy, academic performance and school transition among orphaned adolescents in southern Uganda.

Introduction: Self-efficacy is critical to adolescents' development. This study examined the relationship between self-efficacy, academic performance and transition to post primary education among orphaned adolescents in southern Uganda. Methods: Longitudinal data from a cluster randomized clinical trial for orphaned adolescents was analyzed. Adolescents (N = 1410) between 10 and 16 years at study initiation, in their last three years of primary schooling were eligible to participate in the study. Data collected at baseline, 12, 24, 36 and 48-months follow-up were analyzed. Ordinary least square and logistic regression analyses were conducted to assess the relationship between adolescents' self-efficacy, academic performance -as measured by Primary Leaving Examinations (PLE) scores, and transition to post primary education. Results: Results indicate that adolescents' self-efficacy was associated with better PLE grades (lower scores indicate better performance [b = -0.05, 95 % CI = -0.09, -0.01, p≤0.01]) and a higher likelihood of transition to post primary education (OR = 1.02, 95 % CI = -0.09, 1.00, 1.03, p≤0.01). Conclusion: Findings point to the importance of integrating components focused on promoting self-efficacy among adolescents -especially those made vulnerable by poverty and HIV/AIDS in low resource settings.

Monitoring adherence to antiretroviral therapy among adolescents in Southern Uganda: comparing Wisepill to Self-report in predicting viral suppression in a cluster-randomized trial.

INTRODUCTION: Optimal antiretroviral therapy (ART) adherence is crucial for improved patient outcomes; however, ART adherence among adolescents living with HIV (ALHIV) is low. Also, the performance of various adherence measures among ALHIV is under contention. We monitored ART adherence and compared Self-report (SR) and Wisepill electronic monitoring (EM) performance in measuring ART adherence and predicting HIV viral suppression among ALHIV. METHODS: Between January 2014 and December 2015, we recruited 702 ALHIV aged 10-16 years into our cluster-randomized controlled trial (2012-2018) in 39 clinics in Uganda. The intervention included a long-term savings child development account, four micro-enterprise workshops and 12 mentorship sessions. Using the entire sample, we performed multilevel logistic regression to predict monthly ART adherence trends for the first year of follow-up. Since it is possible that the intervention had different effects on SR and EM adherence, we used participants in the control arm only to compare adherence using SR and EM and to calculate their sensitivity and specificity in predicting viral suppression. RESULTS: There was a significant decline in adherence for each month throughout the entire follow-up period regardless of the group assigned. Good ART adherence was measured at 79.2% (75.2-82.6%) and 97.0% (95.4-98.1%) using EM and SR, respectively. Overall, 64.3% (60.6-67.9%) had suppressed viral loads. The specificities for EM and SR in predicting viral non-suppression were 80.4% (73.6-85.7%) and 96.7% (93.3-98.4%), while the sensitivities were 22.9% (15.0-33.3%) and 1.8% (0.4-6.9%), respectively. The area under the curve was low for both EM and SR, at 53.6% (45.7-61.5%) and 56.2% (53.2-59.3%), respectively. There was high agreement (78%) between SR and EM in monitoring adherence. CONCLUSIONS: Our findings highlighted the need for strategies for sustained optimal adherence. SR and EM measure adherence with a considerable agreement; however, neither is an accurate predictor of virological outcome. There is still a need for an acceptable, feasible and affordable method that predicts viral suppression among ALHIV.

The Long-term (5-year) Impact of a Family Economic Empowerment Intervention on Adolescents Living with HIV in Uganda: Analysis of Longitudinal Data from a Cluster Randomized Controlled Trial from the Suubi+Adherence Study (2012-2018).

150/150 words.We examined the 5-year impact of an economic empowerment (EE) intervention on: adherence, viral suppression, sexual risk-taking intentions (primary); and physical health, educational and economic (secondary) outcomes among adolescents living with HIV in Uganda. The Suubi + Adherence study (2012-2018) randomized clinics to: (1) Control group, n = 19 clinics, n = 344 participants; (2) intervention group which received matched savings accounts, mentorship, financial management and, business development training, n = 20 clinics, n = 358 participants. Participants completed post-baseline assessments at 12-, 24-, 36-, and 48-months. No significant differences in viral load, sexual risk-intentions and physical health perception were observed. The intervention group had better adherence (at 24-months) (Contrast=-0.28; 95% CI: -0.55, -0.004), higher school enrolment (OR = 2.18; 95% CI:1.30, 3.66); reported savings OR = 2.03 (1.29, 3.18) and higher savings (Contrast = 0.40; 95% CI:0.10, 0.70) than controls at 48-months. The EE intervention was efficacious in improving adherence, school enrolment, and economic outcomes creating opportunities for improved overall health among adolescents living with HIV.

PrEP acceptability and initiation among women engaged in sex work in Uganda: Implications for HIV prevention.

BACKGROUND: Women engaged in sex work (WESW) are disproportionately affected by HIV. In Uganda, HIV prevalence among WESW is estimated at 37%, accounting for 18% of all new infections in the country. WESW experience poverty, gender-based violence, and other issues that reduce their power and limit their ability to negotiate condom use. Female-controlled strategies, including pre-exposure prophylaxis (PrEP), may afford women more transmission protection, but barriers to access and use persist. This cross-sectional study examined baseline PrEP acceptability and initiation among WESW recently enrolled in a randomized clinical trial in Uganda to test the impact of a combination HIV risk reduction and economic empowerment intervention on sexual risk outcomes (clinicaltrials.gov, NCT03583541). METHODS: A total of 542 WESW from 19 high HIV-prevalent geographical areas were enrolled in the Kyaterekera study between June 2019 and March 2020. Women were eligible for the study if they: (1) were age 18 or over; (2) reported engagement in transactional sex (a sex act in exchange for pay) in the past 30 days; and (3) reported engagement in one or more episodes of unprotected sex in the past 30 days. Women completed a baseline assessment, were tested for HIV and other sexually transmitted infections (STIs) at enrollment, and were connected with antiretroviral therapy (ART), STI treatment, or PrEP, based on need and interest. Descriptive statistics examined baseline data on PrEP acceptability and initiation. Independent variables (i.e. years in sex work, recent sexual coercion, perceived HIV and sex work stigmas, harmful alcohol use, barriers to medical care, and social support) were derived from the empirical literature and women's self-report. Bivariate analysis was performed to test associations between main effects of these variables. Using binomial logistic regression, predictive models were evaluated for two distinct outcomes-PrEP acceptability and PrEP initiation/uptake. FINDINGS: At baseline, 59% of women (n = 322) tested HIV negative. Among WESW testing negative, 11% (n = 36) were already PrEP enrolled. Most women reported willingness to use PrEP (n = 317; 91%). Slightly over half of WESW not already on PrEP agreed to initiate PrEP (n = 158; 55%). Logistic regression models demonstrate that acceptability of or willingness to use PrEP was significantly associated with fewer years engaged in sex work (AOR= ·18, 95% CI 0·05-·66, p<·01) and greater perceived social support from family (AOR= 1·39, 95% CI 1·03 -1.88, p<·05). PrEP initiation was negatively associated with greater perceived social support from friends (AOR=·81, 95% CI ·68-0·97, p<·05) and positively associated with higher perceived stigma due to sex work among family members (AOR=2·20, 95% CI 1·15-4·22, p<·05). INTERPRETATION: Despite endorsing PrEP use, many WESW remain reluctant to use it. This gap in prevention practice highlights the heart of a failing PrEP prevention cascade. Findings point to the important role family and friend support may play in destigmatizing sex work and PrEP use for women. Social and structural-level efforts are needed to improve educational messaging and to integrate positive messaging into health promotion campaigns for women and their families, while also working toward decriminalizing sex work. FUNDING: This paper was made possible with funding from United States National Institute of Mental Health (Grant number: R01MH116768).

Costing of a Multiple Family Group Strengthening Intervention (SMART-Africa) to Improve Child and Adolescent Behavioral Health in Uganda.

Reliable cost estimates are key to assessing the feasibility, affordability, and cost-effectiveness of interventions. We estimated the economic costs of a multiple family group (MFG) intervention-child and adolescent mental health evidence-based practices (CAMH-EBP) implemented under the SMART-Africa study, seeking to improve family functioning and reduce child and adolescent behavior problems-delivered through task-shifting by community health workers (CHWs) or parent peers (PPs) in school settings in Uganda. This prospective microcosting analysis was conducted from a provider perspective as part of a three-armed randomized controlled trial of the MFG intervention involving 2,391 participants aged 8-13 years and their caregivers in 26 primary schools. Activity-specific costs were estimated and summed, and divided by actual participant numbers in each study arm to conservatively calculate total per-child costs by arm. Total per-child costs of the MFG-PP and MFG-CHW arms were estimated at US$346 and US$328, respectively. The higher per-child cost of the MFG-PP arm was driven by lower than anticipated attendance by participants recruited to this arm. Personnel costs were the key cost driver, accounting for approximately 70% of total costs because of intensive supervision and support provided to MFG facilitators and intervention quality assurance efforts. This is the first study estimating the economic costs of an evidence-based MFG intervention provided through task-shifting strategies in a low-resource setting. Compared with the costs of other family-based interventions ranging between US$500 and US$900 in similar settings, the MFG intervention had a lower per-participant cost; however, few comparisons are available in the literature. More costing studies on CAMH-EBPs in low-resource settings are needed.

Pediatric, adolescent, and young adult cancer in an HIV-infected rural sub-Saharan African population.

Youth living with HIV (YLWHIV) have an increased cancer risk. Our objective is to describe the prevalence of medical record (MR) reported suspected cancers in a contemporary cohort of YLWHIV in Uganda that was assembled through MR reviews of patients 10 to 24 years old across 35 Ugandan HIV care health facilities. Clinical data were abstracted to identify suspected cancer cases and information about HIV care. Among 3728 YLWHIV, we identified eight suspected cancer cases. The most common suspected types were Kaposi sarcoma (n=4) followed by lymphoma (n=3). Challenges encountered in data abstraction were missing data for several variables and confirmatory cancer diagnostic information. In follow-up of suspected cases referred for diagnosis at the Uganda Cancer Institute (UCI), none had diagnosis records in UCI files. In addition, ∼18% of patients (n=686) were lost-to-follow-up (LTF) defined as not having returned to the clinic in ≥183 days and three patients died from presumed Kaposi sarcoma. Although our results suggest that cancer is rare in YLWHIV, the possibility that the cancer burden is higher cannot be excluded due to incomplete information in MRs and high LTF rates. Further, our study raises concern that patients referred for diagnosis are not accessing potential life-saving care.

Family-level correlates of disruptive behavior challenges among children in Southwestern Uganda.

Introduction: This exploratory study sought to examine the extent to which family-level factors are associated with disruptive behavioral disorder (DBD) symptoms, including oppositional defiant disorder (ODD) and conduct disorder (CD) among school children in Uganda, a low-resource country in SSA. The examination of key influences within the SSA context is important to guide needed investments in mental health care and family-level support. Importantly, identifying families at higher risk can inform the development of contextualized family interventions that reinforce positive parenting practices. Method: We analyzed baseline data (N = 2110) from the NIH-funded Strengthening Mental health And Research Training in Africa (SMART Africa) scale-up study in Southwestern Uganda. Children aged 8-13 and their caregivers were recruited from 30 public primary schools. DBDs were examined using the DBD rating scale, Iowa Conners, and Impairment scales. Logistic regression analysis using cluster adjusted robust standard errors to adjust for within-school clustering was conducted to assess the association between DBD symptoms and family-level factors, including parenting practices, marital status, and family size. Results: Results indicate that poor parental supervision (OR = 1.17; CI: 1.13, 1.21; P <.001), divorced families (OR = 1.33; CI: 1.03, 1.72; P <.05), and widowed families (OR = 1.48; CI: 1.10, 2.00; P <.01) were associated with higher DBD symptoms among children. On the other hand, caregiver age (OR = 0.99; CI: 0.98, 0.99; P <.01) was associated with lower DBD symptoms among children. Moreover, caregiver employment and parental education were not statistically significant in the model. Conclusion: Findings from the study reveal an association between family-level factors and behavioral difficulties among children in Uganda suggesting that divorced and widowed families may benefit from additional support in caring for children. Moreover, caregivers may also benefit from programs that provide tools for effective parental supervision.

The efficacy and cost-effectiveness of a family-based economic empowerment intervention (Suubi + Adherence) on suppression of HIV viral loads among adolescents living with HIV: results from a Cluster Randomized Controlled Trial in southern Uganda.

INTRODUCTION: Evidence from low-resource settings indicates that economic insecurity is a major barrier to HIV treatment adherence. Economic empowerment (EE) interventions have the potential to improve adherence outcomes among adolescents living with HIV (ALWHIV) by mitigating the effects of poverty. This study aims to assess the efficacy and cost-effectiveness of a savings-led family-based EE intervention, Suubi + Adherence, aimed at improving antiretroviral therapy (ART) adherence outcomes ALWHIV in Uganda. METHODS: Adolescents (mean age 12 years at enrolment; 56% female) receiving ART for HIV at 39 health centres were randomized to Suubi + Adherence intervention (n = 358) or bolstered standard of care (BSOC; n = 344). A difference-in-differences analysis was employed to assess the change in the proportion of virally suppressed adolescents (HIV RNA viral load <40 copies/mL) over 24 months. The cost-effectiveness analysis examined how much the intervention cost to virally suppress one additional adolescent relative to BSOC from the healthcare provider perspective. RESULTS: At 24 months, the intervention was associated with an 8.85-percentage point [95% confidence interval (CI) 0.80 to 16.90 percentage points] increase in the proportion of virally suppressed adolescents between the study arms (p = 0.032). Per-participant costs were US$177 and US$263 for the BSOC and intervention groups respectively. The incremental cost of virally suppressing one additional adolescent was estimated at US$970 [95% CI, US$508 to 10,725] over two years. CONCLUSIONS: Our results support the integration of family-based EE interventions into adherence-support strategies as part of routine HIV care in low-resource settings to address the underlying economic drivers of poor ART adherence among ALWHIV. Moreover, per-participant costs to achieve viral suppression do not seem prohibitive compared to other community-based adherence interventions targeted at ALWHIV in low-resource settings. Further research on combination interventions at the nexus of economic security and HIV treatment and care is needed to inform the development of feasible and scalable HIV policies and programmes.

Development and external validation of a risk calculator to predict internalising symptoms among Ugandan youths affected by HIV.

The aim of the study was to develop and externally validate a model to predict individualized risk of internalizing symptoms among AIDS-affected youths in low-resource settings in sub-Saharan Africa. Longitudinal data from 558 Ugandan adolescents orphaned by AIDS was used to develop our predictive model. Least Absolute Shrinkage and Selection Operator logistic regression was used to select the best subset of predictors using 10-fold cross-validation. External validation of the final model was conducted in a sample of 372 adolescents living with HIV in Uganda. Best predictors for internalizing symptoms were gender, family cohesion, social support, asset ownership, recent sexually transmitted infection (STI) diagnosis, physical health self-rating, and previous poor mental health; area under the curve (AUC)  = 72.2; 95% CI  = 67.9-76.5. For adolescents without history of internalizing symptoms, the AUC = 69.0, 95% CI = 63.4-74.6, and was best predicted by gender, drug use, social support, asset ownership, recent STI diagnosis, and physical health self-rating. Both models were well calibrated. External validation in adolescents living with HIV sample was similar, AUC = 69.7; 95% CI = 64.1-75.2. The model predicted internalizing symptoms among African AIDS-affected youth reasonably well and showed good generalizability. The model offers opportunities for the design of public health interventions addressing poor mental health among youth affected by HIV/AIDS.

Predicting the individualized risk of poor adherence to ART medication among adolescents living with HIV in Uganda: the Suubi+Adherence study.

INTRODUCTION: Achieving optimal adherence to antiretroviral therapy (ART) among adolescents living with HIV (ALWHIV) is challenging, especially in low-resource settings. To help accurately determine who is at risk of poor adherence, we developed and internally validated models comprising multi-level factors that can help to predict the individualized risk of poor adherence among ALWHIV in a resource-limited setting such as Uganda. METHODS: We used data from a sample of 637 ALWHIV in Uganda who participated in a longitudinal study, "Suubi+Adherence" (2012 to 2018). The model was developed using the Least Absolute Shrinkage and Selection Operator (LASSO) penalized regression to select the best subset of multi-level predictors (individual, household, community or economic-related factors) of poor adherence in one year's time using 10-fold cross-validation. Seventeen potential predictors included in the model were assessed at 36 months of follow-up, whereas adherence was assessed at 48 months of follow-up. Model performance was evaluated using discrimination and calibration measures. RESULTS: For the model predicting poor adherence, five of the 17 predictors (adherence history, adherence self-efficacy, family cohesion, child poverty and group assignment) were retained. Its ability to discriminate between individuals with and without poor adherence was acceptable; area under the curve (AUC) = 69.9; 95% CI: 62.7, 72.8. There was no evidence of possible areas of miscalibration (test statistic = 1.20; p = 0.273). The overall performance of the model was good. CONCLUSIONS: Our findings support prediction modelling as a useful tool that can be leveraged to improve outcomes across the HIV care continuum. Utilizing information from multiple sources, the risk prediction score tool applied here can be refined further with the ultimate goal of being used in a screening tool by practitioners working with ALWHIV. Specifically, the tool could help identify and provide early interventions to adolescents at the highest risk of poor adherence and/or viral non-suppression. However, further fine-tuning and external validation may be required before wide-scale implementation.

Relationship Between Mental Health and HIV Transmission Knowledge and Prevention Attitudes Among Adolescents Living with HIV: Lessons from Suubi + Adherence Cluster Randomized Study in Southern Uganda.

We assessed the effect of depression, hopelessness, and self-concept on HIV prevention attitudes and knowledge about infection, transmission and sexual risk behavior among adolescents living with HIV in Uganda. Utilizing longitudinal data from 635 adolescents living with HIV, multiple ordinary least square regression was used to evaluate associations between the three indicators of mental health functioning at baseline and HIV knowledge and prevention attitudes at 12-months follow-up. We found that depression (ß = - 0.17; 95% CI - 0.31, - 0.04) and hopelessness (ß = - 0.16; 95% CI - 0.28, - 0.04) scores at baseline were associated with a 0.17 and 0.16 average reduction in HIV prevention attitudes and HIV knowledge scores, respectively at 12-months follow-up. However, self-concept was not significantly associated with HIV knowledge or prevention attitudes. Adolescents living with HIV with greater levels of hopelessness are at increased risk of having limited HIV knowledge while those with greater symptoms of depression had less favorable HIV prevention attitudes.

Family Economic Empowerment, Family Social Support, and Sexual Risk-Taking Behaviors Among Adolescents Living With HIV in Uganda: The Suubi+Adherence Study.

PURPOSE: This study examined the effect of a family economic empowerment (EE) intervention and family support on sexual risk-taking behaviors among adolescents living with HIV in rural Uganda. METHODS: We used data from the Suubi + Adherence study, a longitudinal cluster randomized clinical trial of 702 adolescents living with HIV aged 10-16 years. Participants were randomly assigned to either the control arm (n = 358) receiving bolstered standard of care or a treatment arm (n = 344) receiving bolstered standard of care plus the family EE intervention. We used mixed-effects models to examine the effect of the EE intervention and family support on sexual risk-taking behaviors at the baseline, 12 months, and 24 months after intervention initiation. RESULTS: Adolescents in both the intervention and control groups did not differ significantly in their sexual risk-taking attitudes at the baseline and over the 24-month follow-up period. Higher levels of caregiver social support were significantly associated with a decrease in attitudes toward sexual risk-taking (ß = -.40, 95%CI = -.51, -.29). More frequent parent-child communication was significantly associated with increased negative sexual risk-taking attitudes (ß = .21, 95%CI = .16, .26). CONCLUSIONS: Although we find no direct relationship between family EE and attitudes related to sexual risk-taking behaviors, we find that a supportive family environment can promote positive attitudes related to sexual risk-taking behaviors. The effectiveness of sexual risk reduction interventions would be enhanced by engaging families and strengthening supportive relationships between adolescents and their caregivers.

Predictors of Depressive Symptoms and Post Traumatic Stress Disorder Among Women Engaged in Commercial Sex Work in Southern Uganda.

This study examined the factors associated with depressive symptoms and post traumatic depressive disorder (PTSD) among economically vulnerable women engaged in commercial sex work (WESW) in southern Uganda. Baseline data from a longitudinal cluster randomized study involving 542 self-identified WESW (18-55 years), recruited from 19 HIV hotspots were analyzed. Hierarchical linear regression modelling was utilized to estimate individual, family-level and economic-level predictors of depressive symptoms and PTSD. Family cohesion, sex work stigma, HIV status, financial distress, household assets, number of children and number of household income earners, were associated with PTSD. Similarly, family cohesion, number of people in the household, HIV status, sex work stigma, financial distress, and household assets, were associated with depressive symptoms. Women engaged in commercial sex work are at a higher risk of HIV and poor mental health outcomes. Sex work stigma and financial distress elevate levels of depressive symptoms and PTSD, over and above an individual's HIV status. Family and economic-level factors have the potential to mitigate the risk of poor mental health outcomes. As such, integrating stigma reduction and economic strengthening components in the programming targeting WESW-a key population, may be critical to address their mental health outcomes.

Suubi+Adherence-Round 2: A study protocol to examine the longitudinal HIV treatment adherence among youth living with HIV transitioning into young adulthood in Southern Uganda.

BACKGROUND: Youth living with HIV (YLHIV) in Sub-Saharan African (SSA) are less likely to adhere to antiretroviral therapy (ART) and other health-related regimens. As a consequence, YLHIV are not only at risk for health problems and mental health comorbidities, but are also at risk for cognitive deficits, including in areas of memory and executive functioning. The Suubi+Adherence study followed 702 adolescents (10-16 years of age) receiving bolstered standard of care and a family economic empowerment intervention comprising an incentivized youth financial savings account (YSA) augmented with financial literacy training (FLT) and peer mentorship. The study findings pointed to superior short-term viral suppression and positive adolescent health and mental health functioning among participants receiving the intervention. The original group of adolescents who received Suubi+Adherence are now transitioning into young adulthood. This paper presents a protocol for the follow-up phase titled Suubi+Adherence Round 2. METHODS: The original cohort in Suubi+Adherence will be tracked for an additional five years (2020-2025). Specifically, the long term follow-up will allow to: 1) ascertain the extent to which the short term outcomes identified in the first 6 years of the intervention are maintained as the same group transitions through young adulthood; and 2) address new scientific questions regarding ART adherence; HIV care engagement; protective health behaviors; and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. Additionally, the team examines the potential mechanisms through which the observed long-term outcomes happen. Moreover, the Suubi+Adherence-Round 2 adds a qualitative component and extends the cost effectiveness component. DISCUSSION: Guided by asset and human development theories, Suubi+Adherence-R2 will build on the recently concluded Suubi+Adherence study to conduct one of the largest and longest running studies of YLHIV in SSA as they transition into young adulthood. The study will address new scientific questions regarding long-term ART adherence, HIV care engagement, protective health behaviors, and the potential of FEE to mitigate the development of HIV-associated neurocognitive disorders in YLHIV. The findings may inform efforts to improve HIV care among Uganda's YLHIV, with potential replicability in other low-resource countries. TRIAL REGISTRATION: ClinicalTrials.gov , ID: NCT01790373.

The Impact of a Family-Based Economic Intervention on the Mental Health of HIV-Infected Adolescents in Uganda: Results From Suubi + Adherence.

PURPOSE: This study examines the extent to which three mental health measures (hopelessness, depression, and poor self-concept) are improved through a family-based economic intervention implemented among adolescents living with HIV in Uganda. METHODS: We used repeated measures from Suubi + Adherence, a large-scale 6-year (2012-2018) longitudinal randomized controlled trial. Bivariate analyses were conducted to test for observable group differences between the intervention and control conditions. Multilevel piecewise repeated measure mixed models were then conducted to assess hypothesized time × intervention interaction in changes in hopelessness, depression, and self-concept using participant-specific follow-up intervals. RESULTS: At 24-month postintervention initiation, adolescents in the intervention condition reported a statistically significant lower hopelessness score than adolescents in the control condition (4.79 vs. 5.56; p = .018; N = 358). At 36-month follow-up, the intervention condition reported a statistically significant lower score on depression in the depression subgroup (N = 344) than the control condition (4.94 vs. 5.81; p = .029). CONCLUSIONS: The results indicate that family-based economic interventions such as Suubi + Adherence can effectively improve the mental health of adolescents living with HIV who evidenced mental health challenges at baseline. Given the promising positive effects of these interventions, at least in the short term, future studies should investigate strategies to promote the sustainability of these mental health benefits.