Does Venue of HIV Testing and Results Disclosure in the Context of a Research Study Affect Adolescent Health and Behavior? Results from a Study in Western Kenya.

Ethical concerns about risks to minor adolescents participating in HIV prevention research is a barrier to their inclusion. One concern is whether HIV testing and results disclosure venue affects the health and behavior of adolescent participants. We assessed for differential effects on quality of life (QOL), depressive symptoms, and sexual behavior due to (1) testing venue (home or health facility) and (2) test result (HIV-positive, HIV-negative, indeterminate). We collected data at three timepoints (baseline, 2-month follow-up, 12-month follow-up) from 113 Kenyan adolescents aged 15-19 (51% female). We analyzed the data using linear mixed effects models for the QOL and depressive symptoms outcomes and a logistic model for the sexual behavior outcome. Results showed a small mental health benefit for adolescents tested for HIV at a health facility compared with home. There was little evidence that testing venue influenced sexual behavior or that test results moderated the effects of HIV testing across all outcomes. The decision to conduct HIV testing at home or a health facility may not be very consequential for adolescents' health and behavior. Findings underscore the need to critically examine assumptions about adolescent vulnerability to better promote responsible conduct of HIV prevention research with youth in sub-Saharan Africa.

Pathways to Depression and Poor Quality of Life Among Adolescents in Western Kenya: Role of Anticipated HIV Stigma, HIV Risk Perception, and Sexual Behaviors.

Depression is a major cause of disease burden and is linked to poor quality of life (QOL) among adolescents. We examined the roles of sexual behaviors, HIV risk perception, and anticipated HIV stigma on depressive symptomatology and QOL among 4096 adolescents in a rural region of western Kenya with a high burden of HIV. Participants were aged 15-19 years, had not been tested for HIV in the previous 6 months, and had never been diagnosed with HIV. Anticipated stigma and risk perception were directly associated with depressive symptomatology and QOL. There was evidence of small indirect effects-through stigma-of risk perception on depressive symptomatology and QOL. Gender moderated relationships between sexual behavior and risk perception, depressive symptomatology, and QOL. Results suggest that developing effective gender-based interventions to address stigma, sexual behavior, and risk perception may be important for improving adolescent well-being in high HIV prevalence contexts.

RESUMEN: La depresión es una de las principales causas de carga de morbilidad y se asocia con una pobre calidad de vida (CdV) de los adolescentes. Nosotros estudiamos el papel de los comportamientos sexuales, la percepción de riesgo del VIH, y el estigma anticipado del VIH en relación con la sintomatología depresiva y la CdV de 4 096 adolescentes provenientes de una región rural del oeste de Kenia con alta carga de VIH. Los participantes, adolescentes de entre 15 y 19 años, no se habían hecho la prueba de detección del VIH en los últimos 6 meses y, además, nunca habían sido diagnosticados con VIH. El estigma anticipado y la percepción de riesgo estaban asociados directamente con la sintomatología depresiva y la CdV. Hubo evidencia de pocos efectos indirectos de percepción de riesgo­generados por el estigma­en la sintomatología depresiva y la CdV. El género moderó las relaciones entre el comportamiento sexual y la percepción de riesgo, la sintomatología depresiva y la CdV. Los resultados sugieren que desarrollar intervenciones con enfoque de género para abordar el tema del estigma, los comportamientos sexuales y la percepción de riesgo, puede ser importante para mejorar el bienestar de los adolescentes que viven en un contexto con alta prevalencia de VIH.

Consent Challenges and Psychosocial Distress in the Scale-up of Voluntary Medical Male Circumcision Among Adolescents in Western Kenya.

In priority sub-Saharan African countries, on the ground observations suggest that the success of voluntary medical male circumcision (VMMC) programs should not be based solely on numbers of males circumcised. We identify gaps in the consent process and poor psychosocial outcomes among a key target group: male adolescents. We assessed compliance with consent and assent requirements for VMMC in western Kenya among males aged 15-19 (N = 1939). We also examined differences in quality of life, depression, and anticipated HIV stigma between uncircumcised and circumcised adolescents. A substantial proportion reported receiving VMMC services as minors without parent/guardian consent. In addition, uncircumcised males were significantly more likely than their circumcised peers to have poor quality of life and symptoms of depression. Careful monitoring of male adolescents' well-being is needed in large-scale VMMC programs. There is also urgent need for research to identify effective strategies to address gaps in the delivery of VMMC services.

Preliminary efficacy of adapted responsive teaching for infants at risk of autism spectrum disorder in a community sample.

This study examined the (a) feasibility of enrolling 12-month-olds at risk of ASD from a community sample into a randomized controlled trial, (b) subsequent utilization of community services, and (c) potential of a novel parent-mediated intervention to improve outcomes. The First Year Inventory was used to screen and recruit 12-month-old infants at risk of ASD to compare the effects of 6-9 months of Adapted Responsive Teaching (ART) versus referral to early intervention and monitoring (REIM). Eighteen families were followed for ~20 months. Assessments were conducted before randomization, after treatment, and at 6-month follow-up. Utilization of community services was highest for the REIM group. ART significantly outperformed REIM on parent-reported and observed measures of child receptive language with good linear model fit. Multiphase growth models had better fit for more variables, showing the greatest effects in the active treatment phase, where ART outperformed REIM on parental interactive style (less directive), child sensory responsiveness (less hyporesponsive), and adaptive behavior (increased communication and socialization). This study demonstrates the promise of a parent-mediated intervention for improving developmental outcomes for infants at risk of ASD in a community sample and highlights the utility of earlier identification for access to community services earlier than standard practice.

Ethnicity, body mass, and genome-wide data.

This article combines social and genetic epidemiology to examine the influence of self-reported ethnicity on body mass index (BMI) among a sample of adolescents and young adults. We use genetic information from more than 5,000 single nucleotide polymorphisms in combination with principal components analysis to characterize population ancestry of individuals in this study. We show that non-Hispanic white and Mexican-American respondents differ significantly with respect to BMI and differ on the first principal component from the genetic data. This first component is positively associated with BMI and accounts for roughly 3% of the genetic variance in our sample. However, after controlling for this genetic measure, the observed ethnic differences in BMI remain large and statistically significant. This study demonstrates a parsimonious method to adjust for genetic differences among individual respondents that may contribute to observed differences in outcomes. In this case, adjusting for genetic background has no bearing on the influence of self-identified ethnicity.

Adherence to sleep apnea therapy and use of lipid-lowering drugs: a study of the healthy-user effect.

BACKGROUND: Evidence that continuous positive airway pressure (CPAP) reduces cardiovascular morbidity comes largely from observational studies. This association may be confounded if CPAP adherents are healthier in ways not measured by investigators. We assessed whether patients adhering to lipid-lowering medications were more adherent to CPAP. METHODS: This was a retrospective cohort study undertaken at the Philadelphia Veterans Affairs (VA) Medical Center (2005-2006) of consecutive patients on lipid-lowering therapy newly initiating CPAP for obstructive sleep apnea. Adherence to medications dispensed via the VA closed-pharmacy system was measured as the proportion of days covered (>/=80% vs < 80%) in the year prior to CPAP initiation. CPAP adherence was defined as >/= 4 h/d of "mask-on" time, measured electronically daily during the first week of CPAP. We examined the association between medication adherence and CPAP adherence using multivariable logistic regression. RESULTS: Complete data were available for 117 of 142 (81.5%) subjects. After adjustment for age, race, medical comorbidity, and sleep apnea-related clinical factors, subjects with low medication adherence demonstrated a 40.1% (95% CI, 30.0-51.0) probability of using CPAP >/= 4 h/d compared with 55.2% (95% CI, 46.9-63.1) for subjects with adequate (>/=80%) medication adherence (adjusted for comparison, odds ratio (OR) = 1.8 [95% CI, 1.0-3.3], P = .04). Married patients were more adherent to medications and CPAP; inclusion of this factor reduced to nonsignificance the association of medication and CPAP adherence (OR = 1.6 [95% CI, 0.9-2.8], P = .12). CONCLUSION: Patients consistently refilling lipid-lowering medications were more adherent to CPAP, suggesting that differences in medication adherence or other health-promoting behaviors should be investigated in future nonrandomized, observational studies linking CPAP adherence and cardiovascular outcomes.

Material resources and population health: disadvantages in health care, housing, and food among adults over 50 years of age.

OBJECTIVES: We examined associations between material resources and late-life declines in health. METHODS: We used logistic regression to estimate the odds of declines in self-rated health and incident walking limitations associated with material disadvantages in a prospective panel representative of US adults aged 51 years and older (N = 15,441). RESULTS: Disadvantages in health care (odds ratio [OR] = 1.39; 95% confidence interval [CI] = 1.23, 1.58), food (OR = 1.69; 95% CI = 1.29, 2.22), and housing (OR = 1.20; 95% CI = 1.07, 1.35) were independently associated with declines in self-rated health, whereas only health care (OR = 1.43; 95% CI = 1.29, 1.58) and food (OR = 1.64; 95% CI = 1.31, 2.05) disadvantage predicted incident walking limitations. Participants experiencing multiple material disadvantages were particularly susceptible to worsening health and functional decline. These effects were sustained after we controlled for numerous covariates, including baseline health status and comorbidities. The relations between health declines and non-Hispanic Black race/ethnicity, poverty, marital status, and education were attenuated or eliminated after we controlled for material disadvantage. CONCLUSIONS: Material disadvantages, which are highly policy relevant, appear related to health in ways not captured by education and poverty. Policies to improve health should address a range of basic human needs, rather than health care alone.

Neighborhood of residence is associated with daily adherence to CPAP therapy.

STUDY OBJECTIVES: Adherence to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea is poor. Risk factors for nonadherence are not well understood but may reflect individual or neighborhood socioeconomic factors. We sought to determine the association of socioeconomic status and initial CPAP adherence. DESIGN: Retrospective cohort study, 2005 to 2006. SETTING: Philadelphia VA Medical Center. PARTICIPANTS: Of 330 consecutive veterans who met study criteria for initiation of CPAP therapy for newly diagnosed sleep apnea, 266 had complete data for study inclusion. INTERVENTIONS: N/A. MEASUREMENTS: Through a multivariable logistic regression model, using an outcome of objectively measured CPAP use - 4 h daily during the first week of treatment, we tested whether patients from higher socioeconomic neighborhoods had higher CPAP adherence. We measured neighborhood socioeconomic status with an index derived from the 2000 U.S. Census at the block group-level composed of median household income, male and female employment, adult high school completion, married households, and minority composition. RESULTS: CPAP adherence > 4 h occurred on 48.9% of 1,805 patient-days observed for the 266 subjects. After adjustment for individual sociodemographic characteristics and medical comorbidity, the probability of daily CPAP use 4 h ranged from 34.1% (95% CI, 26.4-42.7) for subjects from a low socioeconomic neighborhood (5th percentile) to 62.3% (95% CI, 53.8-70.1) for subjects from a high (95th percentile) neighborhood. CONCLUSIONS: In a retrospective cohort of veterans, initial CPAP adherence was closely associated with higher neighborhood socioeconomic factors. Future investigation should target specific impediments to adherence in the home and neighborhood environment.