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1.
J Int AIDS Soc ; 23(12): e25641, 2020 12.
Artículo en Inglés | MEDLINE | ID: mdl-33314786

RESUMEN

INTRODUCTION: There have been very few randomized clinical trials of interventions for alcohol use disorders (AUD) in people living with HIV (PLWH) in African countries. This is despite the fact that alcohol use is one of the modifiable risk factors for poor virological control in PLWH on antiretroviral therapy. METHODS: Sixteen clinic clusters in Zimbabwe were selected through stratified randomization and randomized 1: 1 to Intervention and Control arms. Inclusion criteria for individual participants were being adult, living with HIV and a probable alcohol use disorder as defined by a score of 6 (women) or 7 (men) on the Alcohol Use Disorders Identification Test (AUDIT). In the Intervention clusters, participants received 8 to 10 sessions of Motivational Interviewing blended with brief Cognitive Behavioural Therapy (MI-CBT). In the control clusters, participants received four Enhanced Usual Care (EUC) sessions based on the alcohol treatment module from the World Health Organisation mhGAP intervention guide. General Nurses from the clinics were trained to deliver both treatments. The primary outcome was a change in AUDIT score at six-month post-randomization. Viral load, functioning and quality of life were secondary outcomes. A random-effects analysis-of-covariance model was used to account for the cluster design. RESULTS: Two hundred and thirty-four participants (n = 108 intervention and n = 126 control) were enrolled across 16 clinics. Participants were recruited from November 2016 to November 2017 and followed through to May 2018. Their mean age was 43.3 years (SD = 9.1) and 78.6% (n = 184) were male. At six months, the mean AUDIT score fell by -6.15 (95% CI -6.32; -6.00) in the MI-CBT arm, compared to a fall of - 3.09 95 % CI - 3.21; -2.93) in the EUC arm (mean difference -3.09 (95% CI -4.53 to -1.23) (p = 0.05). Viral load reduced and quality of life and functioning improved in both arms but the difference between arms was non-significant. CONCLUSIONS: Interventions for hazardous drinking and AUD comprising brief, multiple alcohol treatment sessions delivered by nurses in public HIV facilities in low-income African countries can reduce problematic drinking among PLWH. Such interventions should be integrated into the primary care management of AUD and HIV and delivered by non-specialist providers. Research is needed on cost-effectiveness and implementation of such interventions, and on validation of cut-points for alcohol use scales in low resource settings, in partnership with those with lived experience of HIV and AUD.

2.
Syst Rev ; 8(1): 244, 2019 10 28.
Artículo en Inglés | MEDLINE | ID: mdl-31661030

RESUMEN

BACKGROUND: Alcohol use disorders (AUDs) in people living with HIV/AIDS (PLWH) are a significant impediment to achieving virological control. HIV non-suppression in PLWH with AUDs is mainly attributable to sub-optimal antiretroviral therapy adherence. Sub-optimal adherence makes control of the epidemic elusive, considering that effective antiretroviral treatment and viral suppression are the two key pillars in reducing new infections. Psychological interventions have been proposed as effective treatments for the management of AUDs in PLWH. Evidence for their effectiveness has been inconsistent, with two reviews (2010 and 2013) concluding a lack of effectiveness. However, a 2017 review that examined multiple HIV prevention and treatment outcomes suggested that behavioural interventions were effective in reducing alcohol use. Since then, several studies have been published necessitating a re-examination of this evidence. This review provides an updated synthesis of the effectiveness of psychological interventions for AUDs in PLWH. METHODS: A search was conducted in the following databases: PubMed, Cochrane Central Register of Trials (CENTRAL), MEDLINE (Ovid), EMBASE, PsychInfo (Ovid) and Clinical trials.gov (clinicaltrials.gov) for eligible studies until August 2018 for psychotherapy and psychosocial interventions for PLWH with AUDs. Two reviewers independently screened titles, abstracts and full texts to select studies that met the inclusion criteria. Two reviewers independently performed data extraction with any differences resolved through discussion. Risk of bias was assessed by two independent reviewers using the Cochrane risk of bias tool, and the concordance between the first and second reviewers was 0.63 and between the first and third reviewers 0.71. Inclusion criteria were randomised controlled trials using psychological interventions in people aged 16 and above, with comparisons being usual care, enhanced usual care, other active treatments or waitlist controls. RESULTS: A total of 21 studies (6954 participants) were included in this review. Studies had diverse populations including men alone, men and women and men who had sex with men (MSM). Use of motivational interviewing alone or blended with cognitive behavioural therapy (CBT) and technology/computer-assisted platforms were common as individual-level interventions, while a few studies investigated group motivational interviewing or CBT. Alcohol use outcomes were all self-report and included assessment of the quantity and the frequency of alcohol use. Measured secondary outcomes included viral load, CD4 count or other self-reported outcomes. There was a lack of evidence for significant intervention effects in the included studies. Isolated effects of motivational interviewing, cognitive behavioural therapy and group therapy were noted. However for some of the studies that found significant effects, the effect sizes were small and not sustained over time. Owing to the variation in outcome measures employed across studies, no meta-analysis could be carried out. CONCLUSION: This systematic review did not reveal large or sustained intervention effects of psychological interventions for either primary alcohol use or secondary HIV-related outcomes. Due to the methodological heterogeneity, we were unable to undertake a meta-analysis. Effectiveness trials of psychological interventions for AUDs in PLWH that include disaggregation of data by level of alcohol consumption, gender and age are needed. There is a need to standardise alcohol use outcome measures across studies and include objective biomarkers that provide a more accurate measure of alcohol consumption and are relatively free from social desirability bias. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD  42017063856 .


Asunto(s)
Trastornos Inducidos por Alcohol , Antirretrovirales/administración & dosificación , Terapia Cognitivo-Conductual , Infecciones por VIH/tratamiento farmacológico , Cumplimiento de la Medicación , Entrevista Motivacional , Psicoterapia , Trastornos Inducidos por Alcohol/psicología , Trastornos Inducidos por Alcohol/terapia , Femenino , Homosexualidad Masculina , Humanos , Masculino , Minorías Sexuales y de Género , Carga Viral
3.
AAS Open Res ; 2: 1, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-32382699

RESUMEN

Biobanks and human genomics applications are key for understanding health, disease and heredity in Africa and globally. Growing interest in these technologies calls for strengthening relevant legal, ethical and policy systems to address knowledge disparities and ensure protection of society, while supporting advancement of science. In Zimbabwe there is limited understanding of ethical, legal, and societal issues (ELSI) for biobanking and genomics. The Genomics Inheritance Law Ethics and Society (GILES) initiative was established in 2015 to explore the current status and gaps in the ethical and legal frameworks, knowledge among various stakeholders, and to establish capacity for addressing ELSI of biobanking and genomics as applied in biomedical and population research, and healthcare. A multi-methods approach was applied including document reviews, focus group discussions and in-depth interviews among health and research professionals, and community members in six provinces comprising urban, peri-urban and rural areas. Emerging findings indicates a need for updating guidelines and policies for addressing ELSI in biobanking and genomics research in Zimbabwe. Emerging terminologies such as biobanking and genomics lack clarity suggesting a need for increased awareness and educational tools for health professionals, research scientists and community members. Common concerns relating to consent processes, sample and data use and sharing, particularly where there is trans-national flow of biospecimens and data, call for nationally tailored ELSI frameworks aligned to regional and international initiatives. This paper describes the strategy undertaken for the development and implementation of the GILES project and discusses the importance of such an initiative for characterisation of ELSI of human biobanking and genomics in Zimbabwe and Africa. Conducting this explorative study among a wide range of stakeholders over a countrywide geographical regions, established one of the most comprehensive studies for ELSI of human biobanking and genomics in Africa.

4.
Syst Rev ; 7(1): 57, 2018 04 10.
Artículo en Inglés | MEDLINE | ID: mdl-29636088

RESUMEN

BACKGROUND: Depression and anxiety symptoms are reported to be common among university students in many regions of the world and impact on quality of life and academic attainment. The extent of the problem of depression and anxiety among students in low- and middle-income countries (LMICs) is largely unknown. This paper details methods for a systematic review that will be conducted to explore the prevalence, antecedents, consequences, and treatments for depression and anxiety among undergraduate university students in LMICs. METHODS: Studies reporting primary data on common mental disorders among students in universities and colleges within LMICs will be included. Quality assessment of retrieved articles will be conducted using four Joanna Briggs critical appraisal checklists for prevalence, randomized control/pseudo-randomized trials, descriptive case series, and comparable cohort/case control. Meta-analysis of the prevalence of depression and anxiety will be conducted using a random effects model which will generate pooled prevalence with their respective 95% confidence intervals. DISCUSSION: The results from this systematic review will help in informing and guiding healthcare practitioners, planners, and policymakers on the burden of common mental disorders in university students in LMICs and of appropriate and feasible interventions aimed at reducing the burden of psychological morbidity among them. The results will also point to gaps in research and help set priorities for future enquiries. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42017064148.


Asunto(s)
Ansiedad/epidemiología , Depresión/epidemiología , Estudiantes , Universidades , Ansiedad/terapia , Depresión/terapia , Países en Desarrollo , Humanos , Prevalencia , Calidad de Vida
5.
J Health Psychol ; 22(10): 1265-1276, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-26893295

RESUMEN

Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted for use in Africa. We selected, culturally adapted and tested the feasibility of a cognitive-behavioural intervention for adherence and for delivery in a clinic setting in Harare, Zimbabwe. The feasibility of the intervention was evaluated using a mixed-methods assessment, including ratings of provider fidelity of intervention delivery, and qualitative assessments of feasibility using individual semi-structured interviews with counsellors (n=4) and patients (n=15). The intervention was feasible and acceptable when administered to 42 patients and resulted in improved self-reported adherence in a subset of 15 patients who were followed up after 6months.


Asunto(s)
Antirreumáticos/uso terapéutico , Terapia Cognitivo-Conductual/métodos , Asistencia Sanitaria Culturalmente Competente/métodos , Infecciones por VIH/tratamiento farmacológico , Cumplimiento de la Medicación/etnología , Evaluación de Procesos y Resultados en Atención de Salud , Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Zimbabwe/etnología
6.
J Acquir Immune Defic Syndr ; 74(2): 158-165, 2017 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-27828875

RESUMEN

BACKGROUND: Antiretroviral (ARV) drug treatment benefits the treated individual and can prevent HIV transmission. We assessed ARV drug use in a community-randomized trial that evaluated the impact of behavioral interventions on HIV incidence. METHODS: Samples were collected in a cross-sectional survey after a 3-year intervention period. ARV drug testing was performed using samples from HIV-infected adults at 4 study sites (Zimbabwe; Tanzania; KwaZulu-Natal and Soweto, South Africa; survey period 2009-2011) using an assay that detects 20 ARV drugs (6 nucleoside/nucleotide reverse transcriptase inhibitors, 3 nonnucleoside reverse transcriptase inhibitors, and 9 protease inhibitors; maraviroc; raltegravir). RESULTS: ARV drugs were detected in 2011 (27.4%) of 7347 samples; 88.1% had 1 nonnucleoside reverse transcriptase inhibitors ± 1-2 nucleoside/nucleotide reverse transcriptase inhibitors. ARV drug detection was associated with sex (women>men), pregnancy, older age (>24 years), and study site (P < 0.0001 for all 4 variables). ARV drugs were also more frequently detected in adults who were widowed (P = 0.006) or unemployed (P = 0.02). ARV drug use was more frequent in intervention versus control communities early in the survey (P = 0.01), with a significant increase in control (P = 0.004) but not in intervention communities during the survey period. In KwaZulu-Natal, a 1% increase in ARV drug use was associated with a 0.14% absolute decrease in HIV incidence (P = 0.018). CONCLUSIONS: This study used an objective, biomedical approach to assess ARV drug use on a population level. This analysis identified factors associated with ARV drug use and provided information on ARV drug use over time. ARV drug use was associated with lower HIV incidence at 1 study site.


Asunto(s)
Antirretrovirales/uso terapéutico , Utilización de Medicamentos , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/prevención & control , Adolescente , Adulto , África , Estudios Transversales , Femenino , Humanos , Masculino , National Institute of Mental Health (U.S.) , Embarazo , Ensayos Clínicos Controlados Aleatorios como Asunto , Estudios Retrospectivos , Estados Unidos , Adulto Joven
7.
JAMA ; 316(24): 2618-2626, 2016 12 27.
Artículo en Inglés | MEDLINE | ID: mdl-28027368

RESUMEN

Importance: Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. Objective: To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care. Design, Setting, and Participants: Cluster randomized clinical trial with 6 months' follow-up conducted from September 1, 2014, to May 25, 2015, in Harare, Zimbabwe. Twenty-four clinics were randomized 1:1 to the intervention or enhanced usual care (control). Participants were clinic attenders 18 years or older who screened positive for common mental disorders on the locally validated Shona Symptom Questionnaire (SSQ-14). Interventions: The Friendship Bench intervention comprised 6 sessions of individual problem-solving therapy delivered by trained, supervised LHWs plus an optional 6-session peer support program. The control group received standard care plus information, education, and support on common mental disorders. Main Outcomes and Measures: Primary outcome was common mental disorder measured at 6 months as a continuous variable via the SSQ-14 score, with a range of 0 (best) to 14 and a cutpoint of 9. The secondary outcome was depression symptoms measured as a binary variable via the 9-item Patient Health Questionnaire, with a range of 0 (best) to 27 and a cutpoint of 11. Outcomes were analyzed by modified intention-to-treat. Results: Among 573 randomized patients (286 in the intervention group and 287 in the control group), 495 (86.4%) were women, median age was 33 years (interquartile range, 27-41 years), 238 (41.7%) were human immunodeficiency virus positive, and 521 (90.9%) completed follow-up at 6 months. Intervention group participants had fewer symptoms than control group participants on the SSQ-14 (3.81; 95% CI, 3.28 to 4.34 vs 8.90; 95% CI, 8.33 to 9.47; adjusted mean difference, -4.86; 95% CI, -5.63 to -4.10; P < .001; adjusted risk ratio [ARR], 0.21; 95% CI, 0.15 to 0.29; P < .001). Intervention group participants also had lower risk of symptoms of depression (13.7% vs 49.9%; ARR, 0.28; 95% CI, 0.22 to 0.34; P < .001). Conclusions and Relevance: Among individuals screening positive for common mental disorders in Zimbabwe, LHW-administered, primary care-based problem-solving therapy with education and support compared with standard care plus education and support resulted in improved symptoms at 6 months. Scaled-up primary care integration of this intervention should be evaluated. Trial Registration: pactr.org Identifier: PACTR201410000876178.


Asunto(s)
Agentes Comunitarios de Salud , Asistencia Sanitaria Culturalmente Competente , Trastornos Mentales/terapia , Atención Primaria de Salud , Solución de Problemas , Psicoterapia , Adulto , Distribución por Edad , Ansiedad/epidemiología , Ansiedad/terapia , Agentes Comunitarios de Salud/educación , Depresión/epidemiología , Depresión/terapia , Femenino , Estudios de Seguimiento , Seropositividad para VIH/epidemiología , Humanos , Masculino , Trastornos Mentales/diagnóstico , Persona de Mediana Edad , Cooperación del Paciente/estadística & datos numéricos , Selección de Paciente , Grupo Paritario , Distribución por Sexo , Evaluación de Síntomas , Resultado del Tratamiento , Adulto Joven , Zimbabwe/epidemiología
8.
PLoS One ; 11(2): e0149335, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-26901519

RESUMEN

BACKGROUND: Provision and scale-up of high quality, evidence-based services is essential for successful international HIV prevention interventions in order to generate and maintain intervention uptake, study integrity and participant trust, from both health service delivery and diplomatic perspectives. METHODS: We developed quality assurance (QAC) procedures to evaluate staff fidelity to a cluster-randomized trial of the NIMH Project Accept (HPTN 043) assessing the effectiveness of a community-based voluntary counseling and testing strategy. The intervention was comprised of three components-Mobile Voluntary Counseling and Testing (MVCT), Community Mobilization (CM) and Post-Test Support Services (PTSS). QAC procedures were based on standardized criteria, and were designed to assess both provider skills and adherence to the intervention protocol. Supervisors observed a random sample of 5% to 10% of sessions each month and evaluated staff against multiple criteria on scales of 1-5. A score of 5 indicated 100% adherence, 4 indicated 95% adherence, and 3 indicated 90% adherence. Scores below 3 were considered unsatisfactory, and protocol deviations were discussed with the respective staff. RESULTS: During the first year of the intervention, the mean scores of MVCT and CM staff across the 5 study sites were 4 (95% adherence) or greater and continued to improve over time. Mean QAC scores for the PTSS component were lower and displayed greater fluctuations. Challenges to PTSS staff were identified as coping with the wide range of activities in the PTSS component and the novelty of the PTSS process. QAC fluctuations for PTSS were also associated with new staff hires or changes in staff responsibilities. Through constant staff monitoring and support, by Year 2, QAC scores for PTSS activities had reached those of MVCT and CM. CONCLUSIONS: The implementation of a large-sale, evidence based HIV intervention requires extensive QAC to ensure implementation effectiveness. Ongoing appraisal of study staff across sites ensures consistent and high quality delivery of all intervention components, in keeping with the goals of the study protocol, while also providing a forum for corrective feedback, additional supervision and retraining of staff. QAC ensures staff fidelity to study procedures and is critical to the successful delivery of multi-site HIV prevention interventions, as well as the delivery of services scaled up in programmatic situations.


Asunto(s)
Participación de la Comunidad , Diplomacia , Infecciones por VIH/diagnóstico , Infecciones por VIH/prevención & control , Tamizaje Masivo , África del Sur del Sahara/epidemiología , Femenino , Infecciones por VIH/epidemiología , Humanos , Masculino , Tailandia/epidemiología
9.
J Public Health Afr ; 7(1): 533, 2016 Aug 17.
Artículo en Inglés | MEDLINE | ID: mdl-28299151

RESUMEN

HIV related stigma and discrimination is a known barrier for HIV prevention and care. We aimed to assess the relationship between socio-economic status (SES) and HIV related stigma in Zimbabwe. This paper uses data from Project Accept, which examined the impact of community-based voluntary counseling and testing intervention on HIV incidence and stigma. Total of 2522 eligible participants responded to a psychometric assessment tool, which assessed HIV related stigma and discrimination attitudes on 4 point Likert scale. The tool measured three components of HIV-related stigma: shame, blame and social isolation, perceived discrimination, and equity. Participants' ownership of basic assets was used to assess the socio-economic status. Shame, blame and social isolation component of HIV related stigma was found to be significantly associated with medium [odds ratio (OR)=1.73, P<0.01] and low SES (OR=1.97, P<0.01), indicating more stigmatizing attitudes by participants belonging to medium and low SES in comparison to high SES. For HIV related stigma and discrimination programs to be effective, they should take into account the socio-economic context of target population.

10.
Int Rev Psychiatry ; 26(4): 453-9, 2014 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-25137111

RESUMEN

Despite the need to improve the quantity and quality of psychiatry training in sub-Saharan Africa (SSA), very little is known about the experiences of psychiatric trainees in the region. This is the first study examining psychiatric trainees in a low-income country in SSA. It was carried out as part of the needs assessment for a unique Medical Education Partnership Initiative (MEPI) programme to find African solutions for medical shortages in Africa. We approached all doctors who had trained in post-graduate psychiatry in Zimbabwe in 2010 and conducted in-depth qualitative interviews with all except one (n = 6). We analysed the data using constant comparison and thematic analysis. Trainees described the apprenticeship model as the programme's primary strength, through providing clinical exposure and role models. Programme weaknesses included shortages in information sources, trainee salaries, trainers, public health education, and in the mental health service. Most respondents were, however, eager to continue practising psychiatry in Zimbabwe, motivated by family ties, national commitment and helping vulnerable, stigmatized individuals. Respondents called for sub-speciality training and for infrastructure and training to do research. Resources need to be made available for psychiatric trainees in more SSA settings to develop public health competencies. However, investment in psychiatry training programmes must balance service provision with trainees' educational needs. Directing investment towards needs identified by trainees may be a cost-effective, context-sensitive way to increase retention and learning outcomes.


Asunto(s)
Creación de Capacidad/métodos , Psiquiatría , Femenino , Humanos , Masculino , Servicios de Salud Mental , Psiquiatría/educación , Recursos Humanos , Zimbabwe/epidemiología
11.
Lancet Glob Health ; 2(5): e267-77, 2014 May.
Artículo en Inglés | MEDLINE | ID: mdl-25103167

RESUMEN

BACKGROUND: Although several interventions have shown reduced HIV incidence in clinical trials, the community-level effect of effective interventions on the epidemic when scaled up is unknown. We investigated whether a multicomponent, multilevel social and behavioural prevention strategy could reduce HIV incidence, increase HIV testing, reduce HIV risk behaviour, and change social and behavioural norms. METHODS: For this phase 3 cluster-randomised controlled trial, 34 communities in four sites in Africa and 14 communities in Thailand were randomly allocated in matched pairs to receive 36 months of community-based voluntary counselling and testing for HIV (intervention group) or standard counselling and testing alone (control group) between January, 2001, and December, 2011. The intervention was designed to make testing more accessible in communities, engage communities through outreach, and provide support services after testing. Randomisation was done by a computer-generated code and was not masked. Data were collected at baseline (n=14 567) and after intervention (n=56.683) by cross-sectional random surveys of community residents aged 18-32 years. The primary outcome was HIV incidence and was estimated with a cross-sectional multi-assay algorithm and antiretroviral drug screening assay. Thailand was excluded from incidence analyses because of low HIV prevalence. This trial is registered at ClinicalTrials.gov, number NCT00203749. FINDINGS: The estimated incidence of HIV in the intervention group was 1.52% versus 1.81% in the control group with an estimated reduction in HIV incidence of 13.9% (relative risk [RR] 0.86, 95% CI 0.73-1.02; p=0.082). HIV incidence was significantly reduced in women older than 24 years (RR=0.70, 0.54-0.90; p=0.0085), but not in other age or sex subgroups. Community-based voluntary counselling and testing increased testing rates by 25% overall (12-39; p=0.0003), by 45% (25-69; p<0·0001) in men and 15% (3-28; p=0.013) in women. No overall effect on sexual risk behaviour was recorded. Social norms regarding HIV testing were improved by 6% (95% CI 3-9) in communities in the intervention group. INTERPRETATION: These results are sufficiently robust, especially when taking into consideration the combined results of modest reductions in HIV incidence combined with increases in HIV testing and reductions in HIV risk behaviour, to recommend the Project Accept approach as an integral part of all interventions (including treatment as prevention) to reduce HIV transmission at the community level. FUNDING: US National Institute of Mental Health, the Division of AIDS of the US National Institute of Allergy and Infectious Diseases, and the Office of AIDS Research of the US National Institutes of Health.


Asunto(s)
Redes Comunitarias , Consejo , Infecciones por VIH/epidemiología , Aceptación de la Atención de Salud , Conducta de Reducción del Riesgo , Adolescente , Adulto , África/epidemiología , Femenino , Infecciones por VIH/diagnóstico , Infecciones por VIH/prevención & control , Conductas Relacionadas con la Salud , Humanos , Incidencia , Masculino , Evaluación de Resultado en la Atención de Salud , Tailandia/epidemiología , Adulto Joven
12.
PLoS One ; 9(6): e99643, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24926999

RESUMEN

BACKGROUND: There is increased focus on HIV prevention with African men who report experiencing childhood sexual (CSA) or physical abuse (CPA). OBJECTIVE: To better understand the effects of a community-based intervention (Project Accept HPTN 043) on HIV prevention behaviors among men who report CSA or CPA experiences. METHODS: Project Accept compared a community-based voluntary mobile counseling and testing (CBVCT) intervention with standard VCT. The intervention employed individual HIV risk reduction planning with motivational interviewing in 34 African communities (16 communities at 2 sites in South Africa, 10 in Tanzania, and 8 in Zimbabwe). Communities were randomized unblinded in matched pairs to CBVCT or SVCT, delivered over 36 months. The post-intervention assessment was conducted using a single, cross-sectional random survey of 18-32 year-old community members (total N = 43,292). We analyzed the effect of the intervention on men with reported CSA or CPA across the African sites. Men were identified with a survey question asking about having experienced CSA or CPA across the lifespan. The effect of intervention on considered outcomes of the preventive behavior was statistically evaluated using the logistic regression models. RESULTS: Across the sites, the rates of CSA or CPA among men indicated that African men reflected the global prevalence (20%) with a range of 13-24%. The statistically significant effect of the intervention among these men was seen in their increased effort to receive their HIV test results (OR 2.71; CI: (1.08, 6.82); P: 0.034). The intervention effect on the other designated HIV prevention behaviors was less pronounced. CONCLUSION: The effect of the intervention on these men showed increased motivation to receive their HIV test results. However, more research is needed to understand the effects of community-based interventions on this group, and such interventions need to integrate other keys predictors of HIV including trauma, coping strategies, and intimate partner violence.


Asunto(s)
Abuso Sexual Infantil/psicología , Redes Comunitarias , Infecciones por VIH/prevención & control , Adolescente , Adulto , Niño , Abuso Sexual Infantil/estadística & datos numéricos , Estudios Transversales , Consejo Dirigido , Infecciones por VIH/epidemiología , Infecciones por VIH/psicología , Humanos , Masculino , National Institute of Mental Health (U.S.) , Prevalencia , Distribución Aleatoria , Sudáfrica/epidemiología , Tanzanía/epidemiología , Estados Unidos , Adulto Joven , Zimbabwe/epidemiología
13.
PLoS One ; 9(1): e87091, 2014.
Artículo en Inglés | MEDLINE | ID: mdl-24489841

RESUMEN

INTRODUCTION: NIMH Project Accept (HPTN 043) is a community- randomized trial to test the safety and efficacy of a community-level intervention designed to increase testing and lower HIV incidence in Tanzania, Zimbabwe, South Africa and Thailand. The evaluation design included a longitudinal study with community members to assess attitudinal and behavioral changes in study outcomes including HIV testing norms, HIV-related discussions, and HIV-related stigma. METHODS: A cohort of 657 individuals across all sites was selected to participate in a qualitative study that involved 4 interviews during the study period. Baseline and 30-month data were summarized according to each outcome, and a qualitative assessment of changes was made at the community level over time. RESULTS: Members from intervention communities described fewer barriers and greater motivation for testing than those from comparison communities. HIV-related discussions in intervention communities were more grounded in personal testing experiences. A change in HIV-related stigma over time was most pronounced in Tanzania and Zimbabwe. Participants in the intervention communities from these two sites attributed community-level changes in attitudes to project specific activities. DISCUSSION: The Project Accept intervention was associated with more favorable social norms regarding HIV testing, more personal content in HIV discussions in all study sites, and qualitative changes in HIV-related stigma in two of five sites.


Asunto(s)
Participación de la Comunidad/psicología , Infecciones por VIH/psicología , Conocimientos, Actitudes y Práctica en Salud , Adolescente , Adulto , África , Femenino , Humanos , Entrevistas como Asunto , Estudios Longitudinales , Masculino , Investigación Cualitativa , Estigma Social , Tailandia
14.
AIDS Behav ; 18(2): 381-9, 2014 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-23474641

RESUMEN

Childhood sexual and physical abuse have been linked to adolescent and adult risky sexual behaviors, including early sexual debut, an increased number of sexual partners, unprotected sex, alcohol and drug use during sex and sexual violence. This paper explores these relationships among both men and women who report histories of childhood abuse from representative samples of communities in three countries in southern and eastern Africa (South Africa, Zimbabwe and Tanzania). Data were collected as part of a 3-year randomized community trial to rapidly increase knowledge of HIV status and to promote community responses through mobilisation, mobile testing, provision of same-day HIV test results and post-test support for HIV. The results indicate that reported childhood sexual and physical abuse is high in all three settings, also among men, and shows strong relationships with a range of sexual risk behaviors, including age at first sex (OR -0.6 (CI: -0.9, -0.4, p < 0.003)-among men, OR -0.7 (CI: -0.9, -0.5, p < 0.001)-among women), alcohol (OR 1.43 (CI: 1.22, 1.68, p < 0.001)-men, OR 1.83 (CI: 1.50, 2.24, p < 0.001)-women) and drug use (OR 1.65 (CI: 1.38, 1.97, p < 0.001)-men, OR 3.14 (CI: 1.95, 5.05, p < 0.001)-women) and two forms of partner violence-recent forced sex (OR 2.22 (CI: 1.66, 2.95, p < 0.001)-men, OR 2.76 (CI: 2.09, 3.64, p < 0.001)-women) and ever being hurt by a partner (OR 3.88 (CI: 2.84, 5.29, p < 0.001)-men, OR 3.06 (CI: 2.48, 3.76, p < 0.001)-women). Individuals abused in childhood comprise between 6 and 29 % of young adult men and women living in these African settings and constitute a population at high risk of HIV infection.


Asunto(s)
Abuso Sexual Infantil/psicología , Maltrato a los Niños/psicología , Asunción de Riesgos , Adolescente , Adulto , Niño , Femenino , Infecciones por VIH/epidemiología , Conocimientos, Actitudes y Práctica en Salud , Encuestas Epidemiológicas , Humanos , Masculino , Oportunidad Relativa , Prevalencia , Distribución por Sexo , Factores Socioeconómicos , Sudáfrica/epidemiología , Trastornos Relacionados con Sustancias/epidemiología , Trastornos Relacionados con Sustancias/psicología , Encuestas y Cuestionarios , Tanzanía/epidemiología , Adulto Joven , Zimbabwe/epidemiología
15.
Cult Health Sex ; 15(9): 1085-100, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-23815101

RESUMEN

Given recent clinical trials establishing the safety and efficacy of adult medical male circumcision (MMC) in Africa, attention has now shifted to barriers and facilitators to programmatic implementation in traditionally non-circumcising communities. In this study, we attempted to develop a fuller understanding of the role of cultural issues in the acceptance of adult circumcision. We conducted four focus-group discussions with 28 participants in Mutoko, Zimbabwe, and 33 participants in Vulindlela, KwaZulu-Natal, South Africa, as well as 19 key informant interviews in both settings. We found the concept of male circumcision to be an alien practice, particularly as expressed in the context of local languages. Cultural barriers included local concepts of ethnicity, social groups, masculinity and sexuality. On the other hand, we found that concerns about the impact of HIV on communities resulted in willingness to consider adult male circumcision as an option if it would result in lowering the local burden of the epidemic. Adult MMC-promotional messages that create a synergy between understandings of both traditional and medical circumcision will be more successful in these communities.


Asunto(s)
Circuncisión Masculina/psicología , Cultura , Masculinidad , Aceptación de la Atención de Salud , Sexualidad/psicología , Adulto , Femenino , Grupos Focales , Infecciones por VIH/prevención & control , Humanos , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/etnología , Población Rural , Sexualidad/etnología , Sudáfrica , Zimbabwe
16.
PLoS One ; 8(7): e68349, 2013.
Artículo en Inglés | MEDLINE | ID: mdl-23874597

RESUMEN

BACKGROUND: National Institute of Mental Health Project Accept (HIV Prevention Trials Network [HPTN] 043) is a large, Phase III, community-randomized, HIV prevention trial conducted in 48 matched communities in Africa and Thailand. The study intervention included enhanced community-based voluntary counseling and testing. The primary endpoint was HIV incidence, assessed in a single, cross-sectional, post-intervention survey of >50,000 participants. METHODS: HIV rapid tests were performed in-country. HIV status was confirmed at a central laboratory in the United States. HIV incidence was estimated using a multi-assay algorithm (MAA) that included the BED capture immunoassay, an avidity assay, CD4 cell count, and HIV viral load. RESULTS: Data from Thailand was not used in the endpoint analysis because HIV prevalence was low. Overall, 7,361 HIV infections were identified (4 acute, 3 early, and 7,354 established infections). Samples from established infections were analyzed using the MAA; 467 MAA positive samples were identified; 29 of those samples were excluded because they contained antiretroviral drugs. HIV prevalence was 16.5% (range at study sites: 5.93% to 30.8%). HIV incidence was 1.60% (range at study sites: 0.78% to 3.90%). CONCLUSIONS: In this community-randomized trial, a MAA was used to estimate HIV incidence in a single, cross-sectional post-intervention survey. Results from this analysis were subsequently used to compare HIV incidence in the control and intervention communities. TRIAL REGISTRATION: ClinicalTrials.gov NCT00203749.


Asunto(s)
Infecciones por VIH/epidemiología , Infecciones por VIH/prevención & control , Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Síndrome de Inmunodeficiencia Adquirida/epidemiología , Síndrome de Inmunodeficiencia Adquirida/prevención & control , Adolescente , Adulto , África/epidemiología , Antirretrovirales/uso terapéutico , Recuento de Linfocito CD4/métodos , Estudios Transversales , Infecciones por VIH/tratamiento farmacológico , Humanos , Incidencia , National Institute of Mental Health (U.S.) , Prevalencia , Tailandia/epidemiología , Estados Unidos , Carga Viral/métodos , Adulto Joven
17.
J Public Health Afr ; 4(1): e1, 2013 Jun 25.
Artículo en Inglés | MEDLINE | ID: mdl-28299090

RESUMEN

Zimbabwe faces an acute generalized HIV/AIDS epidemic combined with rapidly deteriorating economic and political conditions, under which levels of domestic violence are on the rise. We aimed to determine possible demographic and behavioral factors associated with physical domestic violence in a rural setting in order to better inform both national and local domestic violence and HIV prevention policies. Using the Project Accept baseline data set, we selected demographic, socio-economic, and behavioral variables that might be associated with physical domestic violence based on a review of the literature. Univariate and multivariate analyses were carried out, and odds ratios (OR) were computed using logistic regression. Women reporting physical domestic violence were significantly more likely to report (i) a history of childhood domestic violence (OR=2.96, P<0.001), (ii) two or more lifetime partners (OR=1.94, P<0.001), (iii) some form of sexual abuse as a child (OR=1.82, not significant), and (iv) low or medium socio-economic status as measured by type of homestead (OR=1.4, P=0.04) than women who reported no experience of physical domestic violence. Married women were less likely to experience physical domestic violence than unmarried women (OR=0.65, P=0.011). Women at greatest risk of domestic violence include those with a personal history of violence or sexual abuse, multiple lifetime partners, and low or medium socio-economic status. Risk assessments and joint interventions for both domestic violence reduction and HIV prevention should target these population groups, which are effective both on the public health and global heath diplomacy levels.

18.
BMC Public Health ; 12: 459, 2012 Jun 20.
Artículo en Inglés | MEDLINE | ID: mdl-22716131

RESUMEN

BACKGROUND: Study-based global health interventions, especially those that are conducted on an international or multi-site basis, frequently require site-specific adaptations in order to (1) respond to socio-cultural differences in risk determinants, (2) to make interventions more relevant to target population needs, and (3) in recognition of 'global health diplomacy' issues. We report on the adaptations development, approval and implementation process from the Project Accept voluntary counseling and testing, community mobilization and post-test support services intervention. METHODS: We reviewed all relevant documentation collected during the study intervention period (e.g. monthly progress reports; bi-annual steering committee presentations) and conducted a series of semi-structured interviews with project directors and between 12 and 23 field staff at each study site in South Africa, Zimbabwe, Thailand and Tanzania during 2009. Respondents were asked to describe (1) the adaptations development and approval process and (2) the most successful site-specific adaptations from the perspective of facilitating intervention implementation. RESULTS: Across sites, proposed adaptations were identified by field staff and submitted to project directors for review on a formally planned basis. The cross-site intervention sub-committee then ensured fidelity to the study protocol before approval. Successfully-implemented adaptations included: intervention delivery adaptations (e.g. development of tailored counseling messages for immigrant labour groups in South Africa) political, environmental and infrastructural adaptations (e.g. use of local community centers as VCT venues in Zimbabwe); religious adaptations (e.g. dividing clients by gender in Muslim areas of Tanzania); economic adaptations (e.g. co-provision of income generating skills classes in Zimbabwe); epidemiological adaptations (e.g. provision of 'youth-friendly' services in South Africa, Zimbabwe and Tanzania), and social adaptations (e.g. modification of terminology to local dialects in Thailand: and adjustment of service delivery schedules to suit seasonal and daily work schedules across sites). CONCLUSIONS: Adaptation selection, development and approval during multi-site global health research studies should be a planned process that maintains fidelity to the study protocol. The successful implementation of appropriate site-specific adaptations may have important implications for intervention implementation, from both a service uptake and a global health diplomacy perspective.


Asunto(s)
Servicios de Salud Comunitaria/organización & administración , Salud Global , Infecciones por VIH/prevención & control , Necesidades y Demandas de Servicios de Salud/organización & administración , Cooperación Internacional , África del Sur del Sahara , Consejo , Características Culturales , Humanos , Desarrollo de Programa , Evaluación de Programas y Proyectos de Salud , Tailandia , Estados Unidos
19.
BMC Infect Dis ; 11: 251, 2011 Sep 24.
Artículo en Inglés | MEDLINE | ID: mdl-21943026

RESUMEN

BACKGROUND: Project Accept is a community randomized, controlled trial to evaluate the efficacy of community mobilization, mobile testing, same-day results, and post-test support for the prevention of HIV infection in Thailand, Tanzania, Zimbabwe, and South Africa. We evaluated the accuracy of in-country HIV rapid testing and determined HIV prevalence in the Project Accept pilot study. METHODS: Two HIV rapid tests were performed in parallel in local laboratories. If the first two rapid tests were discordant (one reactive, one non-reactive), a third HIV rapid test or enzyme immunoassay was performed. Samples were designated HIV NEG if the first two tests were non-reactive, HIV DISC if the first two tests were discordant, and HIV POS if the first two tests were reactive. Samples were re-analyzed in the United States using a panel of laboratory tests. RESULTS: HIV infection status was correctly determined based on-in country testing for 2,236 (99.5%) of 2,247 participants [7 (0.37%) of 1,907 HIV NEG samples were HIV-positive; 2 (0.63%) of 317 HIV POS samples were HIV-negative; 2 (8.3%) of 24 HIV DISC samples were incorrectly identified as HIV-positive based on the in-country tie-breaker test]. HIV prevalence was: Thailand: 0.6%, Tanzania: 5.0%, Zimbabwe 14.7%, Soweto South Africa: 19.4%, Vulindlela, South Africa: 24.4%, (overall prevalence: 14.4%). CONCLUSIONS: In-country testing based on two HIV rapid tests correctly identified the HIV infection status for 99.5% of study participants; most participants with discordant HIV rapid tests were not infected. HIV prevalence varied considerably across the study sites (range: 0.6% to 24.4%). TRIAL REGISTRATION: ClinicalTrials.gov registry number NCT00203749.


Asunto(s)
Transmisión de Enfermedad Infecciosa/prevención & control , Infecciones por VIH/diagnóstico , Infecciones por VIH/prevención & control , Vigilancia de la Población/métodos , Adolescente , Adulto , África , Técnicas de Laboratorio Clínico/métodos , Femenino , Humanos , Masculino , Proyectos Piloto , Tailandia , Adulto Joven
20.
Lancet Infect Dis ; 11(7): 525-32, 2011 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-21546309

RESUMEN

BACKGROUND: In developing countries, most people infected with HIV do not know their infection status. We aimed to assess whether HIV testing could be increased by combination of community mobilisation, mobile community-based voluntary counselling and testing (VCT), and support after testing. METHODS: Project Accept is underway in ten communities in Tanzania, eight in Zimbabwe, and 14 in Thailand. Communities at each site were paired according to similar demographic and environmental characteristics, and one community from each pair was randomly assigned to receive standard clinic-based VCT (SVCT), and the other community was assigned to receive community-based VCT (CBVCT) plus access to SVCT. Randomisation and assignment of communities to intervention groups was done by the statistics centre by computer; no one was masked to treatment assignment because the interventions were community based. Intervention was provided for about 3 years (2006-09). The primary endpoint of HIV incidence is pending completion of assessments after the intervention. In this interim analysis, we examined the secondary endpoint of uptake in HIV testing, differences in characteristics of clients receiving their first HIV test, and repeat testing. Analyses were limited to clients aged 16-32 years. This study is registered with ClinicalTrials.gov, number NCT00203749. FINDINGS: The proportion of clients receiving their first HIV test during the study was higher in CBVCT communities than in SVCT communities in Tanzania (2341 [37%] of 6250 vs 579 [9%] of 6733), Zimbabwe (5437 [51%] of 10,700 vs 602 [5%] of 12,150), and Thailand (7802 [69%] of 11,290 vs 2319 [23%] 10,033). The mean difference in the proportion of clients receiving HIV testing between CBVCT and SVCT communities was 40·2% (95% CI 15·8-64·7; p=0·019) across three community pairs (one per country). HIV prevalence was higher in SVCT communities than in CBVCT communities, but CBVCT detected almost four times more HIV cases than did SVCT across the three study sites (952 vs 264; p=0·003). Repeat HIV testing in CBVCT communities increased in all sites to reach 28% of all those testing for HIV by the end of the intervention period. INTERPRETATION: CBVCT should be considered as a viable intervention to increase detection of HIV infection, especially in regions with restricted access to clinic-based VCT and support services after testing. FUNDING: US National Institute of Mental Health, HIV Prevention Trials Network (via US National Institute of Allergy and Infectious Diseases), and US National Institutes of Health.


Asunto(s)
Serodiagnóstico del SIDA/métodos , Redes Comunitarias , Infecciones por VIH/diagnóstico , VIH/aislamiento & purificación , Adolescente , Adulto , Distribución de Chi-Cuadrado , Consejo/métodos , Femenino , Infecciones por VIH/sangre , Infecciones por VIH/epidemiología , Infecciones por VIH/psicología , Humanos , Incidencia , Masculino , Unidades Móviles de Salud , Prevalencia , Población Rural , Tanzanía/epidemiología , Tailandia/epidemiología , Adulto Joven , Zimbabwe/epidemiología
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