The Relationship between Age at Initiation of Regular Drinking of Alcohol and Viral Suppression Status, and Depression Symptoms Among People Living with HIV in South-Western Uganda.

Alcohol use is an important factor in achieving and maintaining viral suppression and optimal mental health among persons with HIV (PWH), however, the effect of age at first regular drinking on viral suppression and depression remains poorly understood. Here, using secondary data from the Alcohol Drinkers' Exposure to Preventive Therapy for Tuberculosis (ADEPT-T) study, we used logistic regression analyses to explore whether there is an association between age at first regular drinking and viral suppression (< 40 copies/ml), or presence of depressive symptoms (Center for Epidemiologic Studies Depression, CES-D ≥ 16) among 262 PWH. The median age at first regular drinking was 20.5 years (IQR: 10), with high proportions starting under age 12 (12.2%) and as teens (13.4%). The majority had an undetectable viral load (91.7%) and 11% had symptoms of probable depression. We found no significant association between age at first regular drinking and viral suppression (i.e., child (aOR = 0.76 95%CI: 0.18, 3.26), adolescent (aOR = 0.74 95%CI: 0.18, 2.97) and young adult (aOR = 1.27 95%CI: 0.40, 3.97)) nor with depressive symptoms (i.e., child (aOR = 0.72 95%CI: 0.19, 2.83), adolescent (aOR = 0.59 95%CI: 0.14, 2.50) and young adult (aOR = 0.57 95%CI: 0.22, 1.53)). Age at first regular drinking among PWH did not appear to be associated with either viral suppression or the presence of depressive symptoms, suggesting interventions may best be focused on the harmful effects of current alcohol use.

Prevalence of autism spectrum disorder symptoms in a paediatric neurology clinic at a tertiary hospital in Uganda.

BACKGROUND: Children with neurological disorders are more likely to present with autism spectrum disorder (ASD) symptoms and get an ASD diagnosis. Despite the large burden of childhood neurological disorders in Uganda, there is limited information on ASD amongst children with neurological disorders in Uganda. AIM: The aim of this study was to determine the prevalence and factors associated with ASD symptoms amongst children attending the paediatric neurology clinic. SETTING: The study was conducted at the paediatric neurology clinic of Mulago National Referral Hospital in Uganda. METHODS: This was a cross-sectional study of 318 children aged 2-9 years. After obtaining consent, a socio-demographic questionnaire and the Social Communication Questionnaire were administered to the caregivers of the children. Additional questions were administered to assess the prenatal, birth and postnatal characteristics of the children. Sample characteristics were described using frequencies and means. Bivariate analysis was carried out using chi-square test and Fisher's exact test. Multiple logistic regression models were used to assess which factors were independently associated with ASD symptoms. RESULTS: The mean age of the children was 5 years and 58.2% were males. The prevalence of significant ASD symptoms was found to be 45%. Factors negatively associated with significant ASD symptoms were female sex (odds ratio [OR] 0.48 [95% CI 0.24, 0.98]) and ability to speak (OR 0.09 [95% CI 0.04, 0.2]). The history of delayed developmental milestones was positively associated with significant ASD symptoms (OR 3.3 [95% CI 1.59, 6.84]). CONCLUSION: The prevalence of ASD symptoms is high in children with neurological disorders. Children, especially those with delayed developmental milestones, should routinely be screened for ASD.

The Effect of a Group-Based Mindfulness and Acceptance Training on Psychological Flexibility and Adherence to Antiretroviral Therapy Among Adolescents in Uganda: An Open-Label Randomized Trial.

Adherence to antiretroviral therapy (ART) is lower in adolescents with HIV (AWH) than in any other age group, partly due to self-regulatory challenges during development. Mindfulness and acceptance training have been shown to support psychological flexibility, a self-regulatory skill that potentially improves adolescent adherence to medication. We assessed the effect of weekly group-based mindfulness and acceptance training sessions on ART adherence among older adolescents (15-19 years) in Kampala, Uganda. One hundred and twenty-two AWH (median age 17, range 15-19 years, 57% female) receiving care at a public health facility in Kampala were randomized 1:1 to receive 4 weekly 90-min group sessions facilitated by experienced trainers or standard-of-care ART services. The training involved (Session 1) clarifying values, (Session 2) skillfully relating to thoughts, (Session 3) allowing and becoming aware of experiences non-judgmentally, and (Session 4) exploring life through trial and error. At baseline, postintervention, and 3-month follow-up, psychological flexibility was measured using the Avoidance and Fusion Questionnaire for Youth (AFQ-Y8), and self-reported ART adherence was assessed using the Morisky Medication Adherence Scale (MMAS-8). At baseline, the intervention and standard-of-care arms had similar psychological flexibility (AFQ-Y8 score:15.45 ± 0.82; 15.74 ± 0.84) and ART adherence (MMAS-8 score: 5.32 ± 0.24; 5.13 ± 0.23). Retention through the study was moderate (71%). Completion of mindfulness and acceptance training was associated with a significant reduction in psychological inflexibility at the 3-month follow-up (AFQ-Y8 score: 12.63 ± 1.06; 14.05 ± 1.07, P = .006). However, no significant differences were observed in self-reported adherence to ART at the 3-month follow-up (MMAS-8 score: 5.43 ± 0.23; 4.90 ± 0.33, P = .522). Group-based mindfulness and acceptance training improved psychological flexibility in this population of adolescents on ART in Uganda but did not significantly improve ART adherence. Future research should explore integrated approaches that combine behavioral management training with other empowerment aspects to improve ART adherence among AWH.

Prevalence of, and factors associated with, alcohol use disorder among young adults (aged 15-24 years) living with HIV/AIDS in low-income and middle-income countries: protocol for a systematic review.

INTRODUCTION: Alcohol use is a global driver of HIV infection and disease progression, mediated through risky behaviour and poor antiretroviral adherence. Most studies about the burden of alcohol use among people living with HIV (PLWH)/AIDS have been done in adult populations, but less is known about young people with HIV, especially in low-income and middle-income countries (LMICs), despite the high level of alcohol use in these settings. The aim of this review is to collate evidence on the prevalence of, and factors associated with, alcohol use disorder (AUD) among young adults (aged 15-24 years) living with HIV/AIDS in LMICs. METHODS AND ANALYSIS: Two experienced librarians will conduct an independent article search in PubMed, PsycINFO, Embase and Web of Science databases, using relevant Medical Subject Headings terms and Boolean operators ('AND', 'OR'). We will include English-language articles that were published in peer-reviewed journals from 1 January 2000, to 25 July 2022, that documented the prevalence of AUD among young people (15-24 years) living with HIV in LMICs. We shall exclude systematic review articles and qualitative studies. Two independent reviewers will screen the articles for eligibility and data will be extracted onto a preset Excel spreadsheet. Data analysis will be done using Stata V.14.0. Heterogeneity will be assessed by use of the I2 statistic and data will be pooled in meta-analyses where appropriate. Publication bias will be assessed using the funnel plot. ETHICS AND DISSEMINATION: Ethical approval is not needed as this systematic review will be based on published studies. Findings from this study will be disseminated via submission for publication in a peer-reviewed journal, at conference presentations, and made available to health professionals, scientists and policy makers. Our data set can be made available on request. REGISTRATION DETAILS: PROSPERO, CRD42022308955.

Promoting HIV-Related Behavioral and Social Science Research Training in Africa: A Case of Uganda.

HIV/AIDS is a major contributor to morbidity and mortality in Sub-Saharan Africa (SSA). Several gaps in HIV/AIDS care persist despite advancements in bio-medical care approaches. Socio-behavioral approaches have been identified to have the capacity to plug these gaps. This calls for HIV- related behavioral and social science research (BSSR) capacity building. Adopting BSSR in HIV may provide insights into the HIV care continuum that is contextual and cost-effective and reveal the missing layer in the fight against HIV on the African continent. The Makerere University Behavioral and Social Sciences Research (Mak-BSSR) program has responded to the call to strengthen capacity in BSSR. This commentary is a call to promote, support, and sustain the collaborations needed to integrate behavioral and social science research into HIV in SSA.

Prevalence and Factors Associated with Depression among Medical Students at Makerere University, Uganda.

BACKGROUND: Depression affects about a third of medical students worldwide. There is paucity of data on depression among medical students in Uganda. The purpose of this study was to establish the prevalence and factors associated with depression among medical students at Makerere University College of Health Science (MakCHS), Uganda. METHODS: A cross-sectional study was conducted among students pursuing a Bachelor of Medicine and Surgery at MakCHS in May and July 2019. Students were enrolled by consecutive sampling, both online using Google Forms and in person for those unable to access internet. The self-reported Patient Health Questionnaire 9 (PHQ9) was administered to assess depression, defined as a PHQ9 score ≥10. Microsoft Excel 2016 and Stata 16 were used for data analysis. RESULTS: Overall, 331 valid responses (mean age 23.1±3.3 years) were submitted (response rate 93.8%). In a majority of participants, the prevalence of depression was 21.5% (n=71) of which 64.1% had moderate depression (n=50). On bivariate analysis, year of study, worrying about academic performance, and lectures were significantly associated with depression. On multivariate analysis, worrying about academic performance (aOR 2.52, 95% CI 1.50-4.22; P<0.001) and lectures (aOR 1.89, 95% CI 1.11-3.22; P=0.018) were significantly associated with depression. CONCLUSION: Depression affects a significant number of medical students at MakCHS. About one in five medical students have depression. Year of study and academic performance were significantly associated with depression. Efforts aimed at identification and evaluation of students at risk, administering appropriate interventions, and follow-up of affected students are vital. Analytical studies aimed at establishing the causative factors and the effects of depression on medical students are recommended.

A narrative analysis of the link between modern medicine and traditional medicine in Africa: a case of mental health in Uganda.

BACKGROUND: Traditional Medicine Practices (TMP) which are premised on indigenous knowledge and experiences within a local context of the culture and environment, are common place in low income countries. In Africa and in Uganda specifically, nearly 80% of the Ugandan population relies on TMP for the care of their mental health but they also use Modern Medicine. There are areas of departure between Traditional and Modern Medical practices in Africa that have been cited. What has attracted less research attention, are the areas of convergence. OBJECTIVE: This paper aims to critically examine the link between Modern Medicine and Traditional Healing Practices in Africa, citing Uganda as case example. METHOD: A Narrative literature review with critical element assessment was undertaken to identify documented points of departure, areas of common practice, and ways in which the two models can co-exist and work together through a carefully thought out integration. RESULTS: Points of departure between Modern Medicine and Traditional Medicine Practices are philosophical underpinnings of both practices, training of practitioners, and methods and ethics of work. Common areas of practice include human rights perspective, descriptions of mental illnesses, clinical diagnostic practice, particularly severer forms, intellectual property rights, and cross prescriptions. Exhibiting cultural humility and responsibility on the side of the Modern Medicine Practitioners is one of the ways to work together with TMPs. CONCLUSION: Points of departure are more documented and explicit and overshadow areas of common practice while the links between the two are mainly implicit but sadly unrecognized. Mental disorders are disorders of the brain and in neuroscience; the brain is culturally and socially constructed. Sociocultural issues therefore cannot be divorced from disorders of the brain and their management. For better patient outcome and patient-centered approach of care, it is necessary to acknowledge and enhance the links in teaching, clinical and policy level and carry out research on how the links could be improved.

Challenges for the implementation of World Health Organization guidelines for acute stress, PTSD, and bereavement: a qualitative study in Uganda.

BACKGROUND: In 2013, the World Health Organization (WHO) published new guidelines for the management of conditions specifically related to stress, including symptoms of acute stress, bereavement, and post-traumatic stress disorder (PTSD). It is important to evaluate potential challenges for the implementation of these guidelines in low-resource settings, however, there is a dearth of research in this area. The current qualitative study aimed to assess perspectives on the feasibility and acceptability of the new guidelines in four clinics that provide mental health services in post-conflict northern Uganda. METHODS: In-depth interviews were conducted with 19 mental health-care providers and program developers in northern Uganda to address three major research objectives: (1) describe the current standard practices and guidelines used for treating conditions related to stress in Uganda; (2) identify barriers and challenges associated with implementing the new WHO guidelines; and (3) identify and describe potential strategies for overcoming these barriers and challenges. An emergent thematic analysis was used to develop a coding scheme for the transcribed interviews. RESULTS: Practices for managing conditions related to stress included group psychological interventions, psychoeducation, and medication for clients with severe signs and symptoms. Several themes were identified from the interviews on barriers to guideline implementation. These included (1) a lack of trained and qualified mental health professionals to deliver WHO-recommended psychological interventions; (2) a perception that psychological interventions developed in high-income countries would not be culturally adaptable in Uganda; and (3) reluctance about blanket statements regarding medication for the management of acute stress symptoms and PTSD. Identified strategies for overcoming these barriers included (1) training and capacity building for current mental health staff; (2) a stepped care approach to mental health services; and (3) cultural modification of psychological interventions to improve treatment acceptability by clients. CONCLUSIONS: Guidelines were viewed positively by mental health professionals in Uganda, but barriers to implementation were expressed. Recommendations for implementation include (1) strengthening knowledge on effectiveness of existing cultural practices for improving mental health; (2) improving supervision capacity of current mental health staff to address shortage in human resources; and (3) increasing awareness of help-seeking clients on the potential effectiveness of psychological vs. pharmacological interventions.

Post-stroke depression among stroke survivors attending two hospitals in Kampala Uganda.

BACKGROUND: The burden of stroke worldwide is increasing rapidly. There is paucity of data on post-stroke depression (PSD) among stroke survivors in Uganda, despite the high prevalence of PSD reported elsewhere. METHODS: In a cross-sectional study, we assessed adult participants with confirmed first stroke with a standardized questionnaire. The Patient Health Questionnaire-9 was used to assess for depression among non-aphasic patients while the Aphasic Depression Rating Scale was administered to aphasic patients. Univariable and multivariable analyses performed to describe associations with PSD. RESULTS: Forty three females (58.9%) and 30 males (41.1%) who had a stroke participated. Fifty eight (79.5%) had ischemic strokes and 12 participants (16.4%) were aphasic. The prevalence of PSD among the study participants was 31.5%. PSD was higher among patients assessed within 6 months after the onset of stroke. PSD was strongly associated with the total Barthel index of activities of daily living (BIADL) score; p=0.001. There was no significant association between demographic characteristics and PSD. CONCLUSION: There is a high prevalence of unrecognized post-stroke depression. Post-stroke depression was strongly associated with the patient's inability to undertake activities of daily life. There is urgent need for integration of screening for and management of post-stroke depression among stroke survivors.

Giving "Sadness" a Name: The Need for Integrating Depression Treatment into HIV Care in Uganda.

Depression is common among people living with HIV/AIDS (PLWHA) in sub-Saharan Africa (SSA), and can have significant consequences for HIV disease progression, treatment response and prevention. Yet mental health services are limited in most HIV care programs in this region, in part due to severe shortages of mental health professionals. To address the need for establishing an effective, sustainable model for integrating depression treatment into HIV care in SSA, we have embarked upon a 3-year research project, INDEPTH Uganda (INtegrating DEPression Treatment and in HIV care in Uganda), to evaluate a task-sharing, protocolized approach to providing antidepressant care in ten HIV clinics in Uganda. In this paper we share our experiences with two treated cases identified during the initial days of implementation, which we believe highlight the potential value and policy implications for task shifting depression care models in under-resourced settings.

Group support psychotherapy for depression treatment in people with HIV/AIDS in northern Uganda: a single-centre randomised controlled trial.

BACKGROUND: Group support psychotherapy (GSP) is a culturally sensitive intervention that aims to treat depression by enhancing social support, teaching coping skills, and income-generating skills. We compared GSP with group HIV education (GHE) for treatment of depression in people with HIV in Uganda. METHODS: In this open-label randomised controlled trial, we included men and women with HIV, aged 19 years or older, who met the Mini International Neuropsychiatric Interview criteria for major depression from an urban HIV care centre in Kitgum district, northern Uganda. Participants were randomly assigned to receive eight weekly sessions of either GSP or GHE. Randomisation was achieved by urn (men and women separately picked a paper containing the intervention allocation from a basket; ratio 1:1), and the intervention sessions were given to gender-specific groups. Participants were followed up immediately after the intervention and 6 months after the end of treatment. The primary outcomes were change in depressive symptom scores (measured with the Self-Reporting Questionnaire) and in function scores (measured with a locally developed method), analysed by intention to treat using cluster-adjusted t tests and permutation tests. This trial is registered with The Pan African Clinical Trials Registry, number PACTR201402000742370. FINDINGS: Between Jan 6, and Jan 20, 2014, we assessed 150 individuals, of whom 109 were randomly assigned to receive eight weekly sessions of either GSP (n=57) or GHE (n=52). Change in mean depression scores immediately after intervention did not differ between groups (mean difference -0·19, 95% CI -1·77 to 1·39, p=0·78). Mean function scores did not differ between groups either (0·24, -0·41 to 0·88; p=0·41). At 6 months after end of treatment, participants in the GSP group had lower mean depression scores than did those in the GHE group (-2·50, -3·98 to 1·02, p value=0·005), and higher function scores (0·74, -0·17 to 1·65, p=0·09) than did participants in the GHE group. No adverse events were reported. INTERPRETATION: The benefits of existing HIV educational interventions in HIV care services could be improved by the addition of GSP content. Potential benefits of the integration of GSP into existing HIV interventions, such as adherence counselling or group HIV educational programmes, should be addressed in future studies. FUNDING: Grand Challenges Canada.

Developing a culturally sensitive group support intervention for depression among HIV infected and non-infected Ugandan adults: a qualitative study.

BACKGROUND: Depression is ranked first among neuropsychiatric diseases that contribute to the burden of disease in low- and middle-income countries. However, access to antidepressants is limited and there is a dearth of locally developed psychotherapeutic interventions targeted to treat depression. AIM: We aimed to obtain information on the cultural understanding of depression symptoms, complications and treatment methods used in post-conflict communities in northern Uganda in order to inform the development of an indigenous group support intervention to treat depression. METHODS: Focus group discussions (FGDs) were conducted with a total of 110 men and women aged 19-68 years. FDGs took place in a private space, lasted about 2-3h and were conducted in the local language for patients and their caregivers and in English for health workers. Interview transcripts from the FGDs were reviewed for accuracy, translated into English and transcribed. QRS Nvivo 10 qualitative data analysis software was used for coding and thematic analysis. RESULTS: Our study revealed community misperceptions about etiology, presentation and treatment of depression. Regardless of HIV status, most FGD participants who were not health workers linked depression symptoms to HIV infection. Although there were concerns about confidentiality of issues disclosed, many FGD participants were supportive of a group support intervention, tailored to their gender and age, that would not only focus on treating depression but also provided them with skills to improve their livelihoods. Simple CBT techniques were deemed culturally appropriate and acceptable. LIMITATION: Generalizability of study findings may be limited given that the sample was primarily of Luo ethnicity yet there are different ethnic populations in the region. CONCLUSION: Local communities can directly inform intervention content. The participants׳ preferences confirmed the need for a gender-specific intervention for depression that extends beyond medications and empowers them emotionally, socially and economically.

Outcomes, feasibility and acceptability of a group support psychotherapeutic intervention for depressed HIV-affected Ugandan adults: a pilot study.

BACKGROUND: Psychotherapy is the recommended first line treatment for mild to moderate depression. However, its availability in low resource settings is limited. We developed a manualized culturally sensitive group support psychotherapeutic intervention for depressed HIV affected Ugandan adults. In this study, we aimed to assess its feasibility, acceptability and impact on depression, functioning, social support and self-esteem. METHODS: A total of 77 depressed individuals were assigned to the group intervention (n=48) and a wait-list control group (n=29), and assessed before, during and at the end of the intervention. The self-reporting questionnaire, a locally relevant function assessment instrument, the Rosenberg self-esteem scale, and the multiple dimensions perceived social support scale were administered to assess depression symptoms, functioning, self-esteem and social support at three assessment periods. Multivariate longitudinal regression models were used to determine change in outcomes over time between the two groups. Participants were asked to evaluate the intervention. RESULTS: Post -intervention assessments indicate that, in comparison to the wait-list control group, the intervention group had a faster reduction in depression symptom scores [OR=0.00,95% CI, 0.00-0.003] and faster increase in functioning scores [OR=4.82, 95% CI, 2.39 to 9.75], social support scores [OR=2.68, 95% CI, 1.50-4.78] and self-esteem [OR=1.90, 95% CI 1.48-2.44]. Sixty-three percent of participants strongly agreed that the intervention had reduced their depression and would recommend it to other depressed individuals. LIMITATIONS: Inadequate study power due to small sample sizes may result in imprecise confidence intervals even when there are significant differences. The use of non-random samples could have resulted in selection bias. CONCLUSIONS: This intervention appears feasible, acceptable and promising in treating depression and restoring function, enhancing social support and self-esteem. Larger and randomized evaluations are warranted.