Impact of Community Support Workers in Rural Ethiopia on Emotional and Psychosocial Health of Persons Living with HIV: Results of a Three-Year Randomized Community Trial.

People living with HIV face multiple psychosocial challenges. In a large, predominantly rural Ethiopian region, 1799 HIV patients new to care were enrolled from 32 sites in a cluster randomized trial using trained community support workers with HIV to provide individual health education, counseling and social support. Participants received annual surveys through 36 months using items drawn from the Centre for Epidemiologic Studies Depression Scale-10, Medical Outcome Study Social Support Survey, and HIV/AIDS Stigma Instrument-PLWA. At 12 months (using linear mixed effects regression models controlling for enrollment site clustering), intervention participants had greater emotional/informational and tangible assistance social support scores, and lower scores assessing depression symptoms and negative self-perception due to HIV status. A significant treatment effect at 36 months was also seen on scores assessing emotional/informational social support, depression symptoms, and internalized stigma. An intervention using peer community support workers with HIV to provide individualized informational and psychological support had a positive impact on the emotional health of people living with HIV who were new to care.(ClinicalTrials.gov protocol ID: 1410S54203, May 19, 2015).

A three-year randomized community trial of community support workers in rural Ethiopia to promote retention in HIV care.

Retention in care is a major challenge for global AIDS control, including sub-Saharan Africa. In a large Ethiopian region, we evaluated an intervention where HIV positive community support workers (CSWs) provided HIV health education, personal counseling and social support for HIV patients new to care. We enrolled 1,799 patients recently entering care from 32 hospitals and health centers, randomized to intervention or control sites. Dates of all clinic visits, plus deaths or transfers were abstracted from HIV medical records. Primary outcomes were gap in clinical care (>90 days from a missed clinical or drug pickup appointment) and death. For 36 months of follow-up, and for the first 12 months after enrollment, weighted risk differences [RD] between treatment arms were modest and non-significant for gap in clinical care, death or either outcome. Through 36 months, 624 of 980 controls and 469 of 819 intervention participants had gaps in clinical care (RD = -5.5%, 95% confidence interval [CI] = -17.9%, 7.0%); 79 controls and 82 intervention participants died (RD = 2.5% 95% CI = -1.7%, 6.8%). Factors including HIV stigma and a volatile political climate may have attenuated the advantages we anticipated, demonstrating how benefits of CSW interventions may depend upon psychosocial, clinical and structural factors particular to specific community settings.

Disclosure of HIV status among patients new to HIV care in Southern Ethiopia: role of perceived social support and other factors.

Reports from Sub-Saharan Africa, with a large HIV-infected population, vary widely in how often HIV status is disclosed to others, including spouses and other partners. We surveyed 1799 Ethiopian HIV patients newly enrolled in care within the previous 3 months at one of 32 local hospitals and health centers about disclosure of HIV status and two perceived social support domains: emotional/informational (EI) and tangible assistance (TA) support. Disclosure to another person was reported by 1389 (77%) persons. Disclosure rates to specific persons were: spouses or other partners = 74%; mothers = 24%; fathers = 16%; children = 26%; other family members = 37%; friends = 19%, and neighbors/other community members = 13%. Disclosure to another person was associated with higher social support scores on both EI and TA domains, marriage, and a longer time knowing HIV status. In multivariate adjusted models, disclosure to any person, as well as disclosure specifically to a spouse or partner, were associated with higher EI and higher TA social support scores. Provision of knowledgeable and emotionally supportive assistance can be an important factor in facilitating HIV disclosure. Helping persons with HIV decide who to disclose to and how to do so in the most positive manner is an essential component of HIV care and support.

Advanced HIV Disease among Males and Females Initiating HIV Care in Rural Ethiopia.

Despite recommendations for rapidly initiating HIV treatment, many persons in sub-Saharan Africa present to care with advanced HIV disease. Baseline survey and clinical data were collected on 1799 adults newly enrolling at 32 district hospitals and local health HIV clinics in rural Ethiopia. Among those with complete HIV disease information, advanced HIV disease (defined as CD4 count <200 cells/mm3 or World Health Organization [WHO] HIV clinical stage III or IV disease) was present in 66% of males and 56% of females ( P < .001). Males (compared to females) had lower CD4 counts (287 cells/mm3 versus 345 cells/mm3), lower body mass index (19.3 kg/m2 versus 20.2 kg/m2), and more WHO stage III or IV disease (46% versus 37%), ( P < .001). Men reported more chronic diarrhea, fevers, cough, pain, fatigue, and weight loss ( P < .05). Most initiating care in this resource-limited setting had advanced HIV disease. Men had poorer health status, supporting the importance of earlier diagnosis, linkage to care, and initiation of antiretroviral therapy.

A multi-site community randomized trial of community health workers to provide counseling and support for patients newly entering HIV care in rural Ethiopia: study design and baseline implementation.

BACKGROUND: Although HIV therapy is delivered to millions globally, treatment default (especially soon after entering care) remains a challenge. Community health workers (CHWs) can provide many services for people with HIV, including in rural and resource-limited settings. OBJECTIVES: We designed and implemented a 32 site community randomized trial throughout southern Ethiopia to assess an intervention using CHWs to improve retention in HIV care. METHODS: Sixteen district hospital and 16 local health center HIV clinics were randomized 1:1 to be intervention or control sites. From each site, we enrolled adults newly entering HIV care. Participants at intervention sites were assigned a CHW who provided: HIV and health education; counseling and social support; and facilitated communication with HIV clinics. All participants are followed through three years with annual health surveys, plus HIV clinic record abstraction including clinic visit dates. CHWs record operational data about their client contacts. RESULTS: 1799 HIV patients meeting inclusion criteria were enrolled and randomized: 59% were female, median age = 32 years, median CD4 + count = 263 cells/mm3, and 41% were WHO Stage III or IV. A major enrollment challenge was fewer new HIV patients initiating care at participating sites due to shortage of HIV test kits. At intervention sites, 71 CHWs were hired, trained and assigned to clients. In meeting with clients, CHWs needed to accommodate to various challenges, including HIV stigma, distance, and clients lacking cell phones. CONCLUSIONS: This randomized community HIV trial using CHWs in a resource-limited setting was successfully launched, but required flexibility to adapt to unforeseen challenges.

Pandemic influenza a in residential summer camps--Maine, 2009.

OBJECTIVE: The aim of this study was to evaluate the preparedness for and response of Maine summer camps to the 2009 pandemic influenza H1N1 (pH1N1). METHODS: We conducted a retrospective web-based survey of the Maine Youth Camping Foundation members at the end of the 2009 camping season. The outcome measures were responses to the pandemic including educational efforts, isolation practices and antiviral usages as well as percentage of influenza-like illness (ILI) and laboratory-confirmed influenza outbreaks among Maine residential summer camps. RESULTS: Of 107 residential camps queried, 91 (85%) responded. Although 43 (47%) of 91 camps reported cases of ILI, and 19 (21%) had outbreaks (ie, 3 or more confirmed cases of pH1N1), no respondents reported closing camps or canceling sessions. Most camps reported that they communicated with campers' families about pH1N1 and implemented control measures, including educating campers and staff about symptoms, isolating ill campers and staff, encouraging increased hand washing and hygiene practices and increasing the availability of hand sanitizers. Of the 43 camps with cases of ILI or laboratory-confirmed pH1N1, 25 (58%) used antiviral medication for treatment, and 18 (42%) used antiviral medications for prophylaxis; antiviral practices varied among camps. CONCLUSIONS: Summer camps in Maine were in general well prepared for pH1N1. Most camps followed public health guidance and implemented preventive measures. Many camps experienced ILI and outbreaks during the season, but did not report major disruptions. Camps should review their preparedness and disease control plans annually and public health authorities should keep guidance and recommendations simple and consistent.

Injury-prevention practices as depicted in G- and PG-rated movies, 2003-2007.

OBJECTIVE: Our goal was to determine if the depiction of injury-prevention practices in children's movies is different from what was reported from 2 earlier studies, which showed infrequent depiction of characters practicing recommended safety behaviors. METHODS: The top-grossing 25 domestic G-rated (general audience) and PG-rated (parental guidance suggested) movies per year for 2003-2007 were included in this study. Movies or scenes were excluded if they were animated, not set in the present day, fantasy, documentary, or not in English. Injury-prevention practices involving motor vehicles, pedestrians, boaters, and bicyclists were recorded for characters with speaking roles. RESULTS: Sixty-seven (54%) of 125 movies met the inclusion criteria for this study. A total of 958 person-scenes were examined: 524 (55%) depicted children and 434 (45%) adults. Twenty-two person-scenes involved crashes or falls, resulting in 3 injuries and no deaths. Overall, 311 (56%) of 555 motor-vehicle passengers were belted; 73 (35%) of 211 pedestrians used crosswalks; 60 (75%) of 80 boaters wore personal flotation devices; and 8 (25%) of 32 bicyclists wore helmets. In comparison with previous studies, usage of safety belts, crosswalks, personal flotation devices, and bicycle helmets increased significantly. CONCLUSIONS: The entertainment industry has improved the depiction of selected safety practices in G- and PG-rated movies. However, approximately one half of scenes still depict unsafe practices, and the consequences of these behaviors are rarely shown. The industry should continue to improve how it depicts safety practices in children's movies. Parents should highlight the depiction of unsafe behaviors and educate children in following safe practices.