Strategies to improve antiretroviral therapy (ART) initiation and early engagement among men in sub-Saharan Africa: A scoping review of interventions in the era of universal treatment.

OBJECTIVES: Men in sub-Saharan Africa (SSA) have lower rates of antiretroviral therapy (ART) initiation and higher rates of early default than women. Little is known about effective interventions to improve men's outcomes. We conducted a scoping review of interventions aimed to increase ART initiation and/or early retention among men in SSA since universal treatment policies were implemented. METHODS: Three databases, HIV conference databases and grey literature were searched for studies published between January 2016 to May 2021 that reported on initiation and/or early retention among men. Eligibility criteria included: participants in SSA, data collected after universal treatment policies were implemented (2016-2021), quantitative data on ART initiation and/or early retention for males, general male population (not exclusively focused on key populations), intervention study (report outcomes for at least one non-standard service delivery strategy), and written in English. RESULTS: Of the 4351 sources retrieved, 15 (reporting on 16 interventions) met inclusion criteria. Of the 16 interventions, only two (2/16, 13%) exclusively focused on men. Five (5/16, 31%) were randomised control trials (RCT), one (1/16, 6%) was a retrospective cohort study, and 10 (10/16, 63%) did not have comparison groups. Thirteen (13/16, 81%) interventions measured ART initiation and six (6/16, 37%) measured early retention. Outcome definitions and time frames varied greatly, with seven (7/16, 44%) not specifying time frames at all. Five types of interventions were represented: optimising ART services at health facilities, community-based ART services, outreach support (such as reminders and facility escort), counselling and/or peer support, and conditional incentives. Across all intervention types, ART initiation rates ranged from 27% to 97% and early retention from 47% to 95%. CONCLUSIONS: Despite years of data of men's suboptimal ART outcomes, there is little high-quality evidence on interventions to increase men's ART initiation or early retention in SSA. Additional randomised or quasi-experimental studies are urgently needed.

Understanding the Unique Barriers and Facilitators that Affect Men's Initiation and Retention in HIV Care: A Qualitative Study to Inform Interventions for Men Across the Treatment Cascade in Malawi.

Men in sub-Saharan Africa are underrepresented in antiretroviral therapy (ART) programs. Our secondary analysis of 40 in-depth interviews with Malawian men living with HIV examined barriers and facilitators for ART initiation versus retention. Interviewees included men who never initiated or initiated ART late (initiation respondents, n = 19); and men who initiated ART but were late for an appointment (retention respondents, n = 21). Transcribed interviews were coded using deductive and inductive coding techniques and analyzed using constant comparison methods. Long wait times, frequent facility visits, and insufficient in-clinic privacy were barriers for initiation and retention. Poor knowledge of ART was primarily a barrier for initiation; unexpected travel was a barrier for retention. Key facilitators for initiation and retention included previous positive experiences with health facilities. Having examples of successful men using ART primarily facilitated initiation; support from spouses and male peers facilitated retention. Results may inform interventions to increase men's engagement in ART services.

Emotion transmission in peer dyads in middle childhood.

This study investigated emotion transmission among peers during middle childhood. Participants included 202 children (111 males; race: 58% African American, 20% European American, 16% Mixed race, 1% Asian American, and 5% Other; ethnicity: 23% Latino(a) and 77% Not Latino(a); Mincome  = $42,183, SDincome  = $43,889; Mage  = 9.49; English-speaking; from urban and suburban areas of a mid-Atlantic state in the United States). Groups of four same-sex children interacted in round-robin dyads in 5-min tasks during 2015-2017. Emotions (happy, sad, angry, anxious, and neutral) were coded and represented as percentages of 30-s intervals. Analyses assessed whether children's emotion expression in one interval predicted change in partners' emotion expression in the next interval. Findings suggested: (a) escalation of positive and negative emotion [children's positive (negative) emotion predicts an increase in partners' positive (negative) emotion], and (b) de-escalation of positive and negative emotion (children's neutral emotion predicts a decrease in partners' positive or negative emotion). Importantly, de-escalation involved children's display of neutral emotion and not oppositely valenced emotion.

Dosing Characteristics of Recombinant Human Luteinizing Hormone or Human Menopausal Gonadotrophin-Derived LH Activity in Patients Undergoing Ovarian Stimulation: A German Fertility Database Study.

OBJECTIVES: The aim of the study was to evaluate dosing of recombinant human luteinizing hormone (r-hLH) or human menopausal gonadotrophin (hMG)-derived medications with LH activity in ovarian stimulation (OS) cycles for in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI). DESIGN: A non-interventional study was performed to analyse data from the German RecDate database (January 2007-December 2011). PARTICIPANTS/MATERIALS, SETTING, METHODS: Starting/total r-hLH/hMG dose, OS duration/cycle number, r-hLH/hMG initiation day (first day of administration), and population/cycle characteristics were assessed in women (≥18 years) undergoing OS for IVF/ICSI using r-hLH or hMG-derived medications (excluding corifollitropin alfa, clomiphene citrate, letrozole, mini/micro-dose human chorionic gonadotrophin, and urofollitropin alone). Data were summarized descriptively. RESULTS: 67,858 identified cycles utilized medications containing r-hLH (10,749), hMG (56,432), or both (677). Mean (standard deviation) OS duration with r-hLH and hMG was 10.1 (4.43) and 9.8 (6.16) days, respectively. Median (25th-75th percentile) r-hLH starting dose (75.0 [75.0-150.0] IU) was consistent across patients regardless of age, infertility diagnosis, or gonadotrophin-releasing hormone (GnRH) protocol. Median (25th-75th percentile) hMG-derived LH activity starting dose was 225.0 (150.0-300.0) IU, regardless of GnRH protocol, but was lower in women aged <35 years and those with ovulation disorders/polycystic ovary syndrome. Median (25th-75th percentile) total dose for r-hLH (750.0 [337.5-1,125.0] IU) and hMG-derived LH activity (1,575.0 [750.0-2,625.0] IU) varied according to patients' age, infertility diagnosis, cycle number, and r-hLH/hMG initiation day. GnRH antagonist use resulted in a numerically higher median total hMG-derived LH activity dose than GnRH agonist use. LIMITATIONS: The data used in this study were taken from electronic medical records relating to a specific timeframe (2007-2011) and therefore may not accurately reflect current clinical practice; however, it is likely that the differences between the two compounds would be maintained. Additionally, secondary data sources may suffer from uniformity and quality issues. CONCLUSIONS: The standard of care for OS cycles is described with respect to IVF/ICSI treatment including an LH component in Germany during the specified timeframe.

Susceptibility to peer influence in adolescents: Associations between psychophysiology and behavior.

The current study investigated in-the-moment links between adolescents' autonomic nervous system activity and susceptibility to three types of peer influence (indirect, direct, continuing) on two types of behavior (antisocial, prosocial). The sample included 144 racially ethnically diverse adolescents (46% male, 53% female, 1% other; M age  = 16.02 years). We assessed susceptibility to peer influence behaviorally using the Public Goods Game (PGG) while measuring adolescents' mean heart rate (MHR) and pre-ejection period (PEP). Three key findings emerged from bivariate dual latent change score modeling: (1) adolescents whose MHR increased more as they transitioned from playing the PGG alone (pre-influence) to playing while simply observed by peers (indirect influence) displayed more prosocial behavior; (2) adolescents whose PEP activity increased more (greater PEP activity = shorter PEP latency) as they transitioned from indirect influence to being encouraged by peers to engage in antisocial behavior (direct influence) engaged in more antisocial behavior; and (3) adolescents whose PEP activity decreased less as they transitioned from direct influence on prosocial behavior to playing the PGG alone again (continuing influence) displayed more continuing prosocial behavior (marginal effect). The discussion focuses on the role of psychophysiology in understanding adolescents' susceptibility to peer influence.

Provider experiences with three- and six-month antiretroviral therapy dispensing for stable clients in Zambia.

Multi-month dispensing of antiretroviral therapy (ART) has been taken to scale in many settings in sub-Saharan Africa with the benefits of improved client satisfaction and decreased client costs. Six-month ART dispensing may further increase these benefits; however, data are lacking. Within a cluster-randomized trial of three- versus six-month dispensing in Malawi and Zambia, we performed a sub-study to explore Zambian provider experiences with multi-month dispensing. We conducted 18 in-depth interviews with clinical officers and nurses dispensing ART as part of INTERVAL in Zambia. Interview questions focused on provider perceptions of client acceptability, views on client sharing and selling of ART, and perceptions on provider workload and clinic efficiency, with a focus on differences between three- and six-month dispensing. Interviews were analyzed using inductive thematic analysis to identify key themes and patterns within the data. Providers perceived significant benefits of multi-month dispensing, with advantages of six-month over three-month dispensing related to a reduced burden on clients, and for reductions in their own workload and clinic congestion. Among nearly all providers, the six-month dispensing strategy was perceived as ideal. Further research is needed to quantify clinical outcomes of six-month dispensing and feasibility of scaling-up this intervention in resource-limited settings.Clinical Trial Number: NCT03101592.

Integrated early childhood development services improve mothers' experiences with prevention of mother to child transmission (PMTCT) programs in Malawi: a qualitative study.

BACKGROUND: HIV-positive mothers who face the dual burden of HIV-positive status and motherhood, may benefit from holistic services that include early childhood development (ECD). We evaluated the acceptability and impact of integrated ECD-PMTCT interventions for mothers and their children. METHODS: We implemented an integrated ECD-PMTCT intervention in 4 health facilities in Malawi for HIV-positive mothers and their infants. WHO/UNICEF Care for Child Development (CCD) education and counseling sessions were offered during routine PMTCT visits between infant age 1.5-24 months. From June-July 2019, we conducted in-depth interviews with 29 mothers enrolled in the intervention for ≥6 months across 4 health facilities. The interview guide focused on perceived impact of the intervention on mothers' ECD and PMTCT practices, including barriers and facilitators, and unmet needs related to the program. Data were coded and analyzed using constant comparison methods in Atlas ti.8. RESULTS: The vast majority of mothers believed the ECD-PMTCT intervention improved their overall experience with the PMTCT services, strengthened their relationship with providers, and excited and motivated them to attend PMTCT services during the postpartum period. Unlike prior experience, mothers felt more welcome at the health facility, and looked forward to the next visit in order to interact with other mothers and learn new ECD skills. Mothers formed new social support networks with other mothers engaged in ECD sessions, and they provided emotional and financial support to one another, including encouragement regarding ART adherence. Mothers believed their infants reached developmental milestones faster compared to non-intervention children they observed at the same age, and they experienced improved engagement in caregiving activities among male caregivers. Nearly half of women requested additional support with depression or anxiety, coping mechanisms to deal with the stresses of life, or support in building positive dynamics with their male partner. CONCLUSION: The integrated ECD-PMTCT intervention improved mother's experiences with PMTCT programs and health care providers, increased ECD practices such as responsive and stimulating parenting, and created social support networks for women with other PMTCT clients.

Attachment Disorganization in Infancy: A Developmental Precursor to Maladaptive Social Information Processing at Age 8.

This study examined infant attachment as a predictor of social information processing (SIP) in middle childhood (n = 82) while controlling for parental sensitivity in middle childhood. Attachment quality was assessed using the Strange Situation. Although attachment insecurity did not predict SIP, attachment disorganization positively predicted the early SIP steps of hostile attributional bias and aggressive goals. Children with disorganized attachments interpreted ambiguous provocations more negatively (as indicating more hostility, rejection, and disrespect and as resulting in more anger) and endorsed significantly more revenge and dominance goals than children with organized attachments. In contrast, parental sensitivity negatively predicted the later SIP step of positive expectations for aggressive responses. Results further our understanding of the adverse outcomes associated with attachment disorganization.

Preadolescents' Daily Peer Victimization and Perceived Social Competence: Moderating Effects of Classroom Aggression.

Few studies have assessed children's daily peer experiences, and even fewer have considered their daily self-perceptions. This daily diary study examined relations between preadolescents' daily reports of peer victimization and perceived social competence, along with moderating effects of classroom aggression. A racially diverse sample of 182 children in 5th grade (105 boys; M age = 10.64 years; 35% White, 31% Black, 17% Hispanic, 17% other or not reported) completed daily measures of peer victimization and perceived social competence, with most children completing measures on 8 school days. Teachers completed measures of aggression for each participating pupil. Four types of peer victimization (verbal victimization, social manipulation, social rebuff, and property attacks) predicted decreased daily perceived social competence. Daily social rebuff predicted decreased daily perceived social competence beyond the effects of the other types of victimization. Classroom aggression moderated the relation of verbal victimization with perceived social competence, such that this relation was significant in classrooms with lower aggression and nonsignificant in classrooms with higher aggression. Results indicate that preadolescents' daily self-perceptions fluctuate with daily victimization by peers, particularly with social rebuff. Findings also suggest that the impact of verbal victimization on children's self-views could be exacerbated in classrooms that better manage peer-to-peer aggression. Accordingly, targeted interventions appear critical for children who continue to experience peer victimization in schools with highly effective aggression prevention programs.

Caregivers' Advice and Children's Bystander Behaviors During Bullying Incidents.

Many bullying prevention programs take a bystander approach, which encourages children to intervene when they are bystanders to bullying incidents. Little is known about how caregivers' advice to children might promote or undermine the positive bystander behaviors targeted by these programs. Accordingly, the aim of the current study was to investigate relations between caregivers' advice and children's bystander behavior during bullying situations. Participants were 106 racially/ethnically diverse 4th- and 5th-grade students (M age = 10.5 years, SD = .71 years), their classmates, and their caregivers. During classroom visits, peers reported on children's bystander behaviors. During home visits, caregivers and children completed a coded interaction task in which caregivers advised children about how to respond to bullying situations at school. Results suggested that (a) bystander intervention was positively predicted by caregivers' advice to help/comfort the victim, (b) bystander passivity was positively predicted by caregivers' advice to not intervene and negatively predicted by caregivers' advice to help/comfort the victim, and (c) bystander reinforcement/assistance of the bully was positively predicted by caregivers' advice not to intervene and not to tell adults. Results support a link between caregivers' advice at home and children's corresponding behavior when they are bystanders to bullying situations at school. These results emphasize the importance of collaboration between families and schools to reduce school bullying. Implications and directions for future research are discussed.

The simultaneous assessment of and relations between children's sympathetic and parasympathetic psychophysiology and their reactive and proactive aggression.

The goal of the current study was to examine the link between children's psychophysiology and aggression when both constructs were assessed simultaneously in scenarios designed to provide the opportunity to aggress for either a reactive reason or a proactive reason. Both sympathetic nervous system (SNS) activity (skin conductance) and parasympathetic nervous system (PNS) activity (respiratory sinus arrhythmia or RSA), as well as their interaction, were included as physiological measures. Participants were 35 5th-grade children who were placed in two virtual-peer scenarios; one scenario provided the opportunity to aggress in response to peer provocation (i.e., reactive aggression) and the other scenario provided the opportunity to aggress for instrumental gain (i.e., proactive aggression). Both skin conductance and RSA were assessed at the time that children were given the opportunity to aggress; this simultaneous assessment of psychophysiology and aggression allowed for an examination of in-the-moment relations between the two constructs. For the reactive scenario, RSA moderated the in-the-moment relation between skin conductance and aggression such that the association was positive at low RSA but negative at high RSA. For the proactive scenario, skin conductance negatively predicted aggression in-the-moment, and RSA positively predicted aggression in-the-moment, but their interaction was not a significant predictor of aggression. Theoretical implications for reactive and proactive aggression and underlying physiological processes are discussed.

Relations Between Actual Group Norms, Perceived Peer Behavior, and Bystander Children's Intervention to Bullying.

The goals of the study were (a) to predict children's intervention in bullying situations from class-level norms for intervention, as well as child-level perceptions of the number of peers who would intervene, and (b) to determine whether these predictions held when accounting for children's levels of empathy, prosocial behavior, and callous-unemotional traits. Participants were 751 racially and ethnically diverse fourth- and fifth-grade students (53.8% female) in 43 classes. Participants completed peer nominations about which classmates they perceived would intervene during bullying situations. Empathy and callous-unemotional traits were assessed via self report, whereas prosocial behavior was measured through peer report. Using multilevel modeling, each child's intervention in bullying was positively predicted from class-level norms for intervention (class means for the percentage of children who nominated each child as intervening) but negatively predicted from child-level perceptions of the number of peers who would intervene, after accounting for the 3 child traits. Class-level findings support past research on group norms which suggest that children are more likely to display a behavior if their peers display the same behavior. Child-level findings support the presence of the "bystander effect" in children's bullying episodes, in which children are less likely to intervene if they believe that more peers will do so. Thus, although children were more likely to intervene in classrooms with cultures that made intervention more normative, within the context of each class's culture, children were more likely to intervene if they perceived that fewer peers would do so.

The Importance of Both Individual Differences and Dyadic Processes in Children's Emotion Expression.

Although children display strong individual differences in emotion expression, they also engage in emotional synchrony or reciprocity with interaction partners. To understand this paradox between trait-like and dyadic influences, the goal of the current study was to investigate children's emotion expression using a Social Relations Model (SRM) approach. Playgroups consisting typically of four same-sex unfamiliar nine-year-old children (N = 202) interacted in a round-robin format (6 dyads per group). Each dyad completed two 5-minute tasks, a challenging frustration task and a cooperative planning task. Observers coded children's emotions during the tasks (happy, sad, angry, anxious, neutral) on a second-by-second basis. SRM analyses provided substantial evidence of both the trait-like nature of children's emotion expression (through significant effects for actor variance, multivariate actor-actor correlations, and multivariate intrapersonal correlations) and the dyadic nature of their emotion expression (through significant effects for partner variance, relationship variance, dyadic reciprocity correlations, and multivariate interpersonal correlations).

Children's physiological and emotional reactions to witnessing bullying predict bystander intervention.

Study goals were to explore whether children clustered into groups based on reactions to witnessing bullying and to examine whether these reactions predicted bullying intervention. Seventy-nine children (M = 10.80 years) watched bullying videos in the laboratory while their heart rate (HR) was measured, and they self-reported on negative emotion after each video. Bullying intervention was assessed by school peers. Two groups emerged based on reactions to the bullying videos: The Emotional group (43% of children) displayed HR acceleration and reported high negative emotion, whereas the Unemotional group (57% of children) showed HR deceleration and reported low negative emotion. Group membership predicted bullying intervention, with peers reporting that Emotional children were more likely to stop a bully than Unemotional children.

Use of latent profile analysis to assess the validity of a peer-rejected group of children.

The goal of this article was to validate the existence and qualities of a peer-rejected group of children using latent profile analysis (LPA). Two separate racially/ethnically diverse samples (Study 1: N = 2,052 second graders; Study 2: N = 594 fourth and fifth graders) completed peer nominations of liking and disliking, from which we calculated Social Preference and Social Impact scores. These scores served as indicators in the LPAs to form LPA groups. In addition, we collected self-, teacher-, and peer-report report data on aggression, depressive symptoms, peer victimization, and social competence. In each sample, an LPA group emerged in which most children were classified as rejected using the Coie, Dodge, and Coppotelli ( 1982 ; CDC) approach (Study 1: 95%; Study 2: 86%). However, in both samples, only a minority of children classified as rejected using the CDC approach fell into this LPA group (Study 1: 46%; Study 2: 36%). The LPA group that mirrored the CDC rejected group received more maladjusted scores than all other LPA groups on aggression, depressive symptoms, peer victimization, and social competence. Furthermore, when compared to children classified as rejected using only the CDC approach, children classified as rejected under both the LPA and CDC approaches were more maladjusted in terms of all sociometric and socioemotional variables. LPA analyses across two developmental levels validated the existence of an empirically derived group of children who overlapped closely with the CDC rejected group. However, this group was considerably smaller and more maladjusted than the CDC rejected group.

Children's social information processing predicts both their own and peers' conversational remarks.

The goal of the current study was to investigate whether children's social information processing (SIP) predicts their conversations with peers, including both their remarks to peers and peers' remarks to them. When children (N = 156; 55% male; United States; Representation by Race: 60% African American, 18% Mixed race, 15% European American, 7% Other; Representation by Latino/a Ethnicity: 22% Latino/a, 78% Not Latino/a; Mincome = $39,419) were 8 years old, we assessed their aggressive and prosocial SIP using the Social Information Processing Application (SIP-AP). When children were 9 years old, they participated in playgroups typically consisting of four same-sex unfamiliar children who interacted in a round-robin format. Each dyad completed a five-minute frustration task and a five-minute planning task. Observers coded children's verbalizations into six prosocial categories (Suggest, Agree, Solicit Input, Ask, Encourage, State Personal) and four antisocial categories (Command, Disagree, Discourage, Aggress). Children with higher aggressive SIP made more antisocial and fewer prosocial statements, whereas children with higher prosocial SIP made more prosocial and fewer antisocial statements. Furthermore, children with higher aggressive SIP elicited more antisocial and fewer prosocial statements from peers, whereas children with higher prosocial SIP elicited more prosocial and fewer antisocial statements from peers. Children's antisocial and prosocial remarks mediated relations between their aggressive SIP and peers' subsequent antisocial and prosocial remarks. Findings are discussed in terms of: (a) the use of SIP to predict more subtle social behaviors in children's social interaction, and (b) cycles of social interactions that maintain and reinforce children's SIP patterns. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Health care workers' perceptions and bias toward men as HIV clients in Malawi and Mozambique: A qualitative study.

Men are underrepresented in HIV services throughout sub-Saharan Africa. Little is known about health care worker (HCW) perceptions of men as clients, which may directly affect the quality of care provided, and HCWs' buy-in for male-specific interventions. Focus group discussions (FGDs) were conducted in 2016 with HCWs from 15 facilities across Malawi and Mozambique and were originally conducted to evaluate barriers to universal treatment (not HCW bias). FGDs were conducted in local languages, recorded, translated to English, and transcribed. For this study, we focused on HCW perceptions of men as HIV clients and any explicit bias against men, using inductive and deductive coding in Atlas.ti v.8, and analyzed using constant comparison methods. 20 FGDs with 154 HCWs working in HIV treatment clinics were included. Median age was 30 years, 59% were female, and 43% were providers versus support staff. HCWs held strong explicit bias against men as clients. Most HCWs believed men could easily navigate HIV services due to their elevated position within society, regardless of facility-level barriers faced. Men were described in pejorative terms as ill-informed and difficult clients who were absent from health systems. Men were largely seen as "bad clients" due to assumptions about men's 'selfish' and 'prideful' nature, resulting in little HCW sympathy for men's poor use of care. Our study highlights a strong explicit bias against men as HIV clients, even when gender and bias were not the focus of data collection. As a result, HCWs may have little motivation to implement male-specific interventions or improve provider-patient interactions with men. Framing men as problematic places undue responsibility on individual men while minimizing institutional barriers that uniquely affect them. Bias in local, national, and global discourses about men must be immediately addressed.

Developing a male-specific counselling curriculum for HIV treatment in Malawi.

Men living with HIV in sub-Saharan Africa have sub-optimal engagement in antiretroviral therapy (ART) Programs. Generic ART counselling curriculum in Malawi does not meet men's needs and should be tailored to men. We developed a male-specific ART counselling curriculum, adapted from the Malawi Ministry of Health (MOH) curriculum based on literature review of men's needs and motivations for treatment. The curriculum was piloted through group counselling with men in 6 communities in Malawi, with focus group discussion (FGD) conducted immediately afterward (n=85 men) to assess knowledge of ART, motivators and barriers to care, and perceptions of the male-specific curriculum. Data were analysed in Atlas.ti using grounded theory. We conducted a half-day meeting with MOH and partner stakeholders to finalize the curriculum (n=5). The male-specific curriculum adapted three existing topics from generic counselling curriculum (status disclosure, treatment as prevention, and ART side effects) and added four new topics (how treatment contributes to men's goals, feeling healthy on treatment, navigating health systems, and self-compassion for the cyclical nature of lifelong treatment. Key motivators for men were embedded throughout the curriculum and included: family wellbeing, having additional children, financially stability, and earning/keeping respect. During the pilot, men reported having little understanding of how ART contributed to their personal goals prior to the male-specific counselling. Men were most interested in additional information about treatment as prevention, benefits of disclosure/social support beyond their sexual partner, how to navigate health systems, and side effects with new regimens. Respondents stated that the male-specific counselling challenged the idea that men were incapable of overcoming treatment barriers and lifelong medication. Male-specific ART counselling curriculum is needed to address men's specific needs. In Malawi context, topics should include: how treatment contributes to men's goals, navigating health systems, self-compassion/patience for lifelong treatment, and taking treatment while healthy.