The Concurrent and Longitudinal Relationship between Perinatal Sleep Difficulties and Depression in a Large Sample of High-Risk Women in South Africa.

INTRODUCTION: Perinatal depression and sleep difficulties are common among studies conducted in high income countries (HIC). This study examines the relationship between sleep difficulties and depression during the perinatal period and over an eight-year follow-up period in South Africa, a middle income country. METHOD: A population cohort of 1238 pregnant women (mean age = 26.33) in 24 township neighborhoods in South Africa were recruited and reassessed six times over the next 8 years post birth with follow-up rates of 96-83%. The relationship between maternal depressed mood and sleep difficulties was examined over time, as well as the relationship of sleep with other socioeconomic, environmental, and psychiatric risk factors. RESULTS: Thirty-five percent of the women reported sleep difficulties during the perinatal period; whereas only 8% reported sleep difficulties at 8-year follow-up. Perinatal sleep difficulties were associated with lower income, lower educational attainment, less access to electricity, more food insecurity, higher rates of interpersonal violence and HIV, alcohol consumption, and depressed mood at 8 years. However, the severity of depressed mood was the strongest predictor of sleep problems longitudinally and cross-sectionally, after accounting for all other risk factors. CONCLUSIONS: We found that the severity of depressed mood is highly associated with sleep difficulties from pregnancy to 8 years post-birth and in a linear relationship, so that higher depressed mood is associated with more sleep problems. TRIAL REGISTRATION: ClinicalTrials.gov registration: # NCT00996528.

Sleep is understudied among people living in poverty in LMIC's. To our knowledge this is the first study to (a) investigate the relationship between sleep difficulties and depression in a sample of high-risk, black women living in poverty in a LMIC and (b) study the relationship between sleep and depression continuously from the perinatal period through 8 years post-partum in a LMIC. The study finds that sleep difficulties and depression are highly correlated during this period even after accounting for other socioeconomic, environmental and psychiatric risk factors in this high-risk population.

Community health workers impact on maternal and child health outcomes in rural South Africa - a non-randomized two-group comparison study.

BACKGROUND: Home visits by paraprofessional community health workers (CHWs) has been shown to improve maternal and child health outcomes in research studies in many countries. Yet, when these are scaled or replicated, efficacy disappears. An effective CHW home visiting program in peri-urban Cape Town found maternal and child health benefits over the 5 years point but this study examines if these benefits occur in deeply rural communities. METHODS: A non-randomized, two-group comparison study evaluated the impact of CHW in the rural Eastern Cape from August 2014 to May 2017, with 1310 mother-infant pairs recruited in pregnancy and 89% were reassessed at 6 months post-birth. RESULTS: Home visiting had limited, but important effects on child health, maternal wellbeing and health behaviors. Mothers reported fewer depressive symptoms, attended more antenatal visits and had better baby-feeding practices. Intervention mothers were significantly more likely to exclusively breastfeed for 6 months (OR: 1.8; 95% CI: 1.1, 2.9), had lower odds of mixing formula with baby porridge (regarded as detrimental) (OR: 0.4; 95% CI: 0.2, 0.8) and were less likely to consult traditional healers. Mothers living with HIV were more adherent with co-trimoxazole prophylaxis (p < 0.01). Intervention-group children were significantly less likely to be wasted (OR: 0.5; 95% CI 0.3-0.9) and had significantly fewer symptoms of common childhood illnesses in the preceding two weeks (OR: 0.8; 95% CI: 0.7,0.9). CONCLUSION: The impact of CHWs in a rural area was less pronounced than in peri-urban areas. CHWs are likely to need enhanced support and supervision in the challenging rural context.

Non-fatal suicidal behaviour, depression and poverty among young men living in low-resource communities in South Africa.

BACKGROUND: Suicide is a serious public health problem in low- and middle-income countries. Understanding the context- and gender-specific risk factors for non-fatal suicidal behaviour is the cornerstone of evidence-based public health interventions to reduce suicide. Poverty and symptoms of depression are well established risk factors for suicidal behaviour. However, little is understood about how proximal economic factors (such as losing one's job, or food insecurity) may confound the effects of symptoms of depression to increase the risk of non-fatal suicidal behaviour in vulnerable populations, such as young men living under conditions of endemic poverty. The aim of this study was to explore the extent to which a wide range of poverty-related variables account for non-fatal suicidal behaviour independent of, or in addition to, symptoms of depression among young men living in low-resource communities in South Africa (SA). METHODS: Data were collected from a clustered sample of 647 young men living in low-resource communities in the Western Cape province of SA. Multivariate regressions were used to identify the associations between poverty-related measures, symptoms of depression, and past-month prevalence of non-fatal suicidal behaviour. RESULTS: Non-fatal suicidal behaviour in the last month was reported by 47 (6.13%) participants: suicidal ideation (n = 43; 5.97%); suicide plan (n = 5; 0.77%); suicide attempt (n = 4; 0.62%), and deliberate self-harm without intent to die (n = 4; 0.62%). Past-month prevalence of non-fatal suicidal behaviour was significantly associated with particular dimensions of poverty (living in a home without a toilet on the premises, having previously been fired, and food insecurity), but not with other dimensions of poverty (such as prolonged unemployment and low levels of income). However, symptoms of depression were a more significant predictor of non-fatal suicidal behaviour than any measure of poverty (aOR=1.093, 95% CI=1.058-1.129, p < .000). CONCLUSIONS: Depressive symptoms are more strongly associated with non-fatal suicidal behaviour than a range of proximal and distal economic factors among young men living under conditions of endemic poverty in South Africa. This has important public health implications and highlights the importance of increasing young men's access to psychiatric services and targeting depression as an integral component of suicide prevention in low resource communities.

Antenatal depressed mood and child cognitive and physical growth at 18-months in South Africa: a cluster randomised controlled trial of home visiting by community health workers.

AIM: To examine the child outcomes at 18-months post-birth of a population cohort of women with antenatal depressed mood, half of whom were randomly chosen to receive perinatal home visits from community health workers during pregnancy. METHOD: Pregnant women in 24 neighbourhoods (98% participation) were randomised by neighbourhood to: (1) standard clinic care (SC; 12 neighbourhoods; n = 594) or (2) the Philani Intervention Program, a home visiting intervention plus standard care (12 neighbourhoods; n = 644). The physical and cognitive outcomes of children of mothers with antenatally depressed mood (Edinburg Perinatal Depression Scale >13) in the intervention condition were compared at 18-months post-birth to children of mothers without depressed mood in pregnancy in both conditions. RESULTS: More than a third of mothers had heightened levels of antenatal depressed mood (35%), similar across conditions. Antenatal depressed mood was significantly associated with being a mother living with HIV, using alcohol and food insecurity. At 18-months, the overall cognitive and motor scale scores on the Bayley Scales of Development were similar. However, 10.3% fewer children of mothers with antenatal depressed mood in the intervention condition had cognitive scores on the Bayley Scales that were less than 85 (i.e., s.d. = 2 lower than normal) compared with children of mothers with antenatal depressed mood in the SC condition. Intervention children of mothers with antenatal depressed mood were also significantly less likely to be undernourished (Weight-for-Age Z-scores < -2). CONCLUSION: Cognitive development and child growth among children born to mothers with antenatal depressed mood can be improved by mentor mother home visitors, probably resulting from better parenting and care received early in life.

Immunisation coverage in the rural Eastern Cape - are we getting the basics of primary care right? Results from a longitudinal prospective cohort study.

BACKGROUND: Immunisations are one of the most cost-effective public health interventions available and South Africa (SA) has implemented a comprehensive immunisation schedule. However, there is disagreement about the level of immunisation coverage in the country and few studies document the immunisation coverage in rural areas. OBJECTIVE: To examine the successful and timely delivery of immunisations to children during the first 2 years of life in a deeply rural part of the Eastern Cape Province of SA. METHODS: From January to April 2013, a cohort of sequential births (N=470) in the area surrounding Zithulele Hospital in the OR Tambo District of the Eastern Cape was recruited and followed up at home at 3, 6, 9, 12 and 24 months post birth, up to May 2015. Immunisation coverage was determined using Road-to-Health cards. RESULTS: The percentages of children with all immunisations up to date at the time of interview were: 48.6% at 3 months, 73.3% at 6 months, 83.9% at 9 months, 73.3% at 12 months and 73.2% at 24 months. Incomplete immunisations were attributed to stock-outs (56%), lack of awareness of the immunisation schedule or of missed immunisations by the mother (16%) and lack of clinic attendance by the mother (19%). Of the mothers who had visited the clinic for baby immunisations, 49.8% had to make multiple visits because of stock-outs. Measles coverage (of at least one dose) was 85.2% at 1 year and 96.3% by 2 years, but 20.6% of babies had not received a second measles dose (due at 18 months) by 2 years. Immunisations were often given late, particularly the 14-week immunisations. CONCLUSIONS: Immunisation rates in the rural Eastern Cape are well below government targets and indicate inadequate provision of basic primary care. Stock-outs of basic childhood immunisations are common and are, according to mothers, the main reason for their children's immunisations not being up to date. There is still much work to be done to ensure that the basics of disease prevention are being delivered at rural clinics in the Eastern Cape, despite attempts to re-engineer primary healthcare in SA.

Regional variations in HIV disclosure in Thailand: implications for future interventions.

People living with HIV (PLH) in Thailand face tremendous challenges, including HIV disclosure. With the advent of antiretroviral (ARV) therapy in Thailand, the positive benefits of HIV disclosure are becoming more salient. However, there are regional variations in the levels of HIV disclosure in Thailand. We examined and compared the levels of HIV disclosure in Northern and Northeastern Thailand. PLH (N = 410) were recruited from four district hospitals in the North and the Northeast. More PLH in the North reported disclosing HIV status to at least one family member in the household. PLH in the Northeast reported significantly lower levels of HIV disclosure within family and outside of family. HIV disclosure remains a significant challenge in Thailand, especially in the Northeast. We propose future interventions focusing on HIV disclosure to address the specific concerns and barriers to HIV disclosure, taking into account the regional differences in HIV disclosure.

Psychosocial predictors of somatic symptoms in adolescents of parents with HIV: a six-year longitudinal study.

The objective of this study was to identify salient parent and adolescent psychosocial factors related to somatic symptoms in adolescents. As part of a larger intervention study conducted in New York, 409 adolescents were recruited from 269 parents with HIV. A longitudinal model predicted adolescent somatization scores six years after baseline assessment. Adolescent somatic symptoms were assessed at baseline and at 3-month intervals for the first two years and then at 6-month intervals using the Brief Symptom Inventory. Baseline data from adolescents and parents were used to predict adolescent somatic symptoms. Variables related to increased adolescent somatic symptoms over six years included being younger and female; an increased number of adolescent medical hospitalizations; more stressful life events; adolescent perception of a highly rejecting parenting style; more parent-youth conflict; no experience of parental death; and parental distress over their own pain symptoms. Our findings extend the literature by virtue of the longitudinal design; inclusion of both parent and child variables in one statistical model; identification of study participants by their potentially stressful living condition rather than by disease or somatic symptom status; and inclusion of serious parental illness and death in the study.

HIV disclosure among adults living with HIV.

Research on disclosure among heterosexual adult person(s) living with HIV (PLH) was reviewed, omitting disclosure of parental HIV to children. Disclosure has been studied within five additional relational contexts: with partners, family members, friends, healthcare professionals and in work settings. Disclosure is higher among women than men, among Latino and white compared to African-American families, and among younger compared to older HIV-positive adults. Most PLH disclose to their sexual partners and family members, yet there is a significant minority who do not disclose. Similarly, rates of disclosure to employers range from 27-68%, suggesting broad variability in perceived consequences of employment disclosures. Of concern, 40% of PLH do not consistently disclose to their healthcare professionals. Rather than examine HIV disclosures in the context of relationships, it is possible to understand disclosures around personal identity. Disclosure decisions are often made to tell everyone (making HIV status a central attribute of one's identity), no one (requiring strategies for securing social support while remaining anonymous) or some people (requiring strategic decisions based on context). Given that disclosure decisions are central to personal identity, future data on disclosure and interventions designed to increase disclosure or comfort with disclosure must focus on communication strategies adopted by PLH to present a coherent identity.

It's not just what you say: relationships of HIV dislosure and risk reduction among MSM in the post-HAART era.

In the post-HAART era, critical questions arise as to what factors affect disclosure decisions and how these decisions are associated with factors such as high-risk behaviors and partner variables. We interviewed 1,828 HIV-positive men who have sex with men (MSM), of whom 46% disclosed to all partners. Among men with casual partners, 41.8% disclosed to all of these partners and 21.5% to none. Disclosure was associated with relationship type, perceived partner HIV status and sexual behaviors. Overall, 36.5% of respondents had unprotected anal sex (UAS) with partners of negative/unknown HIV status. Of those with only casual partners, 80.4% had >1 act of UAS and 58% of these did not disclose to all partners. This 58% were more likely to self-identify as gay (versus bisexual), be aware of their status for <5 years and have more partners. Being on HAART, viral load and number of symptoms were not associated with disclosure. This study - the largest conducted to date of disclosure among MSM and one of the few conducted post-HAART - indicates that almost 1/5th reported UAS with casual partners without disclosure, highlighting a public health challenge. Disclosure needs to be addressed in the context of relationship type, partner status and broader risk-reduction strategies.

Self-monitoring of behaviour as a risk reduction strategy for persons living with HIV.

To reduce the HIV-related transmission behaviours of persons living with HIV (PLH), a few efficacious interventions have been designed and evaluated. However, these interventions were delivered at relatively high cost, both in terms of time and resources. Given the challenges for health providers and community agencies in delivering these interventions, alternatives are needed. One possible intervention is allowing PLH to self-monitor their HIV transmission risk behaviour. Previous research suggests that self-monitoring of HIV-risk related behaviours may be a useful risk reduction strategy. This paper examines the impact of repeated risk assessments for behavioural self-monitoring as an intervention strategy for reducing sexual and substance use risk behaviours. A total of 365 PLH, recruited from community clinics, health management organizations, and health departments, completed self-assessments over time. Increased self-monitoring resulted in increases in protected sex with sexual partners of HIV-negative or unknown serostatus, and changes in attitudes conducive to reducing risk. Self-monitoring is a relatively low cost and easily implementable strategy for reducing the HIV-related transmission risk of PLH.

Pro-social and problematic social network influences on HIV/AIDS risk behaviours among newly homeless youth in Los Angeles.

We examined the social network composition among newly homeless youth over time and assessed how pro-social and problematic peers affected sexual and drug-using HIV/AIDS risk-behaviours among 183 youth in Los Angeles County, California. The percentage of newly homeless youth who reported that 'most' or 'all' of their friends were attending school, had jobs, and got along with their families was 73%, 24%, and 50% respectively. Logistic regression models indicated that presence of these pro-social peers reduced HIV risk behaviours at two years; odds of HIV-risk were lower with a greater number of peers who attend school, have a job, or have positive family relationships or if networks change over time to include more of these peers. Presence of problematic peers increased the likelihood of HIV risk-taking; odds of HIV risk behaviours increased with a greater number of peers at baseline who steal, have overdosed, have been arrested, or are in a gang, or if networks change to include more of these peers. Interventions should target newly homeless youth in networks that contain problematic peers, but should strive to harness the naturally occurring pro-social peer influences present in these networks.

Stigmatization and shame: consequences of caring for HIV/AIDS patients in China.

Using a representative sample of 478 doctors, nurses, and lab technicians working with people living with HIV/AIDS (PLWHA), a cross-sectional study was conducted to assess the impact of the AIDS epidemic on medical care systems and service providers in China. Correlation analyses showed significant association between internalized shame reported by service providers and their perception of being stigmatized due to working with PLWHA. Multivariate analyses revealed that the perceived level of institutional support for AIDS care was significantly related to the stigmatization and shame reported by the service providers. The study findings suggest that improved institutional support for AIDS care at the facility level and HIV-related stigma reduction intervention are crucial to maintain a high quality performance by the workforce in the health care system.

Families living with HIV.

Given the historical emergence of the AIDS epidemic first among gay men in the developed world, HIV interventions have primarily focused on individuals rather than families. Typically not part of traditional family structures, HIV-positive gay men in Europe and the US lived primarily in societies providing essential infrastructure for survival needs that highly value individual justice and freedom. Interventions were thus designed to focus on at-risk individuals with programmes that were age and gender segregated. As the epidemic has unfolded, the early focus on individuals has become inadequate: families live with HIV, not just individuals. Families' structure, economy, migration patterns, and developmental life cycles are affected by HIV, and these changes radiate throughout the community creating parallel stresses. Family-based, intergenerational models of detection, prevention and treatment services offer enhanced opportunities for effective interventions and suggest very different intervention settings and strategies. However, these models also require addressing the family's basic needs for survival and security in order to be successfully implemented and sustained over time. As HIV was an opportunity for marginalized persons in the developed world to 'turn their life around', the strengths of families in the developing world may be mobilized to contribute to the community's long-term health, survival and security needs.

Predictors of sexual transmission risk behaviors among HIV-positive young men.

Reduction in the incidence of high-risk sexual behaviors among HIV-positive men is a priority. We examined the roles of proximal substance use and delinquency-related variables, and more distal demographic and psychosocial variables as predictors of serious high-risk sexual behaviors among 248 HIV-positive young males, aged 15-24 years. In a mediated latent variable model, demographics (ethnicity, sexual orientation and poverty) and background psychosocial factors (coping style, peer norms, emotional distress, self-esteem and social support) predicted recent problem behaviors (delinquency, common drug use and hard drug use), which in turn predicted recent high-risk sexual behaviors. Hard drug use and delinquency were found to predict sexual risk behaviors directly, as did lower self-esteem, white ethnicity and being gay/bisexual. Negative peer norms strongly influenced delinquency and substance use and positive coping predicted less delinquency. In turn, less positive coping and negative peer norms exerted indirect effects on sexual transmission risk behavior through delinquency and hard drug use. Results suggest targeting hard drug use, delinquency, maladaptive peer norms, dysfunctional styles of escaping stress and self-esteem in the design of intervention programs for HIV-positive individuals.

Intricacies and inter-relationships between HIV disclosure and HAART: a qualitative study.

This study aimed to understand whether and how highly active antiretroviral treatment (HAART) affects views and patterns of disclosure and how disclosure interacts with treatment decisions. One hundred and fifty-two HIV-positive adults (52 MSM, 56 women and 44 IDU men) from four US cities participated in two to three-hour, semi-structured interviews in 1998-99. Results indicate that HAART interacts with and shapes HIV disclosure issues in several ways. Medications may 'out' people living with HIV. Thus, in different settings (e.g. work, prisons, drug rehabs and public situations), some try to hide medications or modify dosing schedules, which can contribute to non-adherence, and affect sexual behaviours. Disclosure of HIV and/or HAART may also result in antagonism from others who hold negative attitudes and beliefs about HAART, potentially impeding adherence. Observable side effects of medications can also 'out' individuals. Conversely, medications may improve appearance, delaying or impeding disclosure. Some wait until they are on HAART and look 'well' before disclosing; some who look healthy as a result of medication deny being HIV-positive. Alternatively, HIV disclosure can lead to support that facilitates initiation of, and adherence to, treatment. HIV disclosure and adherence can shape one another in critical ways. Yet these interactions have been under-studied and need to be further examined. Interventions and studies concerning each of these domains have generally been separate, but need to be integrated, and the importance of relationships between these two areas needs to be recognized.

Impact of parent death and an intervention on the adjustment of adolescents whose parents have HIV/AIDS.

The impact of parental death and the efficacy of a coping-skills intervention were examined on the adjustment of 211 adolescent children of parents with HIV/AIDS (PWH) over a 2-year period. During the follow-up period, 35% of the PWH died. Using longitudinal structural equation model, controlling for prior measures of adjustment at baseline, the authors found that children of deceased PWH reported significantly more emotional distress and problem behaviors 2 years later. Youth randomized with their parent to a coping-skills intervention reported significantly fewer problem behaviors and sexual partners 2 years later. Also, adolescents were better-adjusted 2 years later when their parents had reported less emotional distress and less severe physical health symptoms at baseline. Female adolescents reported more emotional distress at baseline and at 2 years than males; male adolescents reported more problem behaviors at baseline than the females.

Test-retest reliability for self-reports of sexual behavior among Thai and Korean respondents.

The purpose of this study was to examine the test-retest reliability for reports of sexual behavior from the National Institutes of Mental Health Multisite HIV Prevention Trial survey for two Asian samples. Thai (N = 37) and Korean (N = 46) respondents aged 19-37 years (M = 29, SD = 4.61) completed face-to-face interviews to assess their sexual risk in their ethnic language 3-7 days apart. Test-retest coefficients ranged from .65 to 1.00 demonstrating acceptable reliability of the survey among Thai and Korean adults. The discussion focuses on the development of HIV risk assessments that take into consideration ethnic diversity found within the Asian and Pacific Islander community.