"Early in the morning, there's tolerance and later in the day it disappears" - The intersection of resource scarcity, stress and stigma in mental health and substance use care in South Africa.

Stress is a challenge among non-specialist health workers worldwide, particularly in low-resource settings. Understanding and targeting stress is critical for supporting non-specialists and their patients, as stress negatively affects patient care. Further, stigma toward mental health and substance use conditions also impacts patient care. However, there is little information on the intersection of these factors. This sub-analysis aims to explore how substance use and mental health stigma intersect with provider stress and resource constraints to influence the care of people with HIV/TB. We conducted semi-structured interviews (N=30) with patients (n=15) and providers (n=15, non-specialist health workers) within a low-resource community in Cape Town, South Africa. Data were analyzed using thematic analysis. Three key themes were identified: (1) resource constraints negatively affect patient care and contribute to non-specialist stress; (2) in the context of stress, non-specialists are hesitant to work with patients with mental health or substance use concerns, who they view as more demanding and (3) stress contributes to provider stigma, which negatively impacts patient care. Findings highlight the need for multilevel interventions targeting both provider stress and stigma toward people with mental health and substance use concerns, especially within the context of non-specialist-delivered mental health services in low-resource settings.

Development and Empirical Test of the Research-Informed South African Relationship Functioning Assessment (SARFA).

Intimate partners play an important role in chronic diseases. Despite the chronic disease burden increase in sub-Saharan Africa, very few culturally-relevant quantitative measures of intimate relationship functioning are available. We conducted an empirical investigation evaluating the psychometric properties of the South African Relationship Functioning Assessment (SARFA) assessing healthy relationship functioning in N = 150 community members (50% women; M age = 27.2 years) living in the Vulindlela area of KwaZulu-Natal, South Africa. Item development was based on prior qualitative research from two South African communities. All assessments were conducted in isiZulu, participants' primary language. An exploratory factor analysis was conducted on the initial 39-item measure. The best-fitting model consisted of one factor with 22 items. The SARFA's internal consistency was α = .94. Convergent validity was observed via significant positive associations (all rs ≥ .38, p < .001) between the SARFA's total score and measures of trust, emotional intimacy, constructive communication, sexual satisfaction, and relationship control (women only). Divergent validity was observed for women only. Encouraging initial psychometric properties of a culturally-relevant measure of relationship functioning in KwaZulu-Natal may have relevance to other communities and potential to be used in research involving couples and health in chronic disease-burdened communities.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment.

BACKGROUND: Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment. METHODS: The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis. RESULTS: Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment. CONCLUSION: Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

A Pilot Study of Training Peer Recovery Specialists in Behavioral Activation in the United States: Preliminary Outcomes and Predictors of Competence.

BACKGROUND: The peer recovery specialist (PRS) workforce has rapidly expanded to increase access to substance-use disorder services for underserved communities. PRSs are not typically trained in evidence-based interventions (EBIs) outside of motivational interviewing, although evidence demonstrates the feasibility of PRS delivery of certain EBIs, such as a brief behavioral intervention, behavioral activation. However, characteristics that predict PRS competency in delivering EBIs such as behavioral activation remain unknown, and are critical for PRS selection, training, and supervision if the PRS role is expanded. This study aimed to explore the outcomes of a brief PRS training period in behavioral activation and identify predictors of competence. METHOD: Twenty PRSs in the United States completed a two-hour training on PRS-delivered behavioral activation. Participants completed baseline and post-training assessments, including roleplay and assessments of PRS characteristics, attitudes towards EBIs, and theoretically relevant personality constructs. Roleplays were coded for competence (behavioral activation specific and PRS skills more broadly, i.e., PRS competence) and changes were assessed from baseline to post-training. Linear regression models tested factors predicting post-training competence, controlling for baseline competence. RESULTS: There was a significant pre-post increase in behavioral activation competence (t = -7.02, p < 0.001). Years working as a PRS significantly predicted post-training behavioral activation skills (B = 0.16, p = 0.005). No variables predicted post-training PRS competence. CONCLUSIONS: This study provides preliminary evidence that behavioral activation may be appropriate for dissemination to PRSs through brief trainings, particularly for PRSs with more work experience. However, additional research is needed to examine predictors of competence among PRSs.

Patient and stakeholder perspectives on impacts of the COVID-19 pandemic on HIV and mental health care delivery in South Africa.

BACKGROUND: The COVID-19 pandemic had a global impact on health systems and the delivery of health services, including for chronic conditions such as HIV. In South Africa, impacts on HIV services have widely been quantitatively described. Across different health settings, patients have also qualitatively described numerous negative impacts to their HIV care. However, patient perspectives on COVID-19 impacts to HIV care in South Africa, the largest HIV care system in the world, have been little explored to date. METHODS: We conducted 29 semi-structured individual interviews with people living with HIV (n = 24) and providers (n = 5) in Cape Town, South Africa. RESULTS: While most patient participants reported continued access to HIV treatment during the pandemic, many described perceiving that the quality of their care declined. Increased structural barriers were described as one contributing factor to this change. Additionally, patients described that reduced privacy in clinical interactions was a key factor negatively influencing their experience of receiving care. CONCLUSION: Findings underscore the importance of ensuring patient privacy for HIV services even during the rearrangement of services in emergencies. It is also important to continue developing models to integrate community mental health services within HIV care delivery in South Africa.

Supporting Treatment for Anti-Retroviral Therapy (START) Together: Protocol for a pilot, randomized, couple-based intervention to promote women's ART adherence and men's engagement in HIV care in KwaZulu-Natal, South Africa.

Background: South Africa currently has the greatest number of people with HIV globally. The country has not yet met its 95-95-95 goals, with different gaps in the HIV care cascade for women and men. This paper reports on a protocol to pilot test a couple-based intervention designed to improve women's antiretroviral therapy (ART) adherence and men's engagement in care in heterosexual couples living in the Vulindlela area of KwaZulu-Natal, South Africa. Study goals are two-fold: (1) assess the acceptability, feasibility, and fidelity of the experimental intervention, START Together, and (2) collect efficacy data on START Together for women's ART adherence, men's engagement in HIV care, and the couple's relationship functioning. Methods: Women (N = 20) who were not engaged with ART adherence (defined via self-reported ART difficulties, record of missed clinic visits, or viral non-suppression) are the target patients; male partners are not required to know or disclose their HIV status to be part of the study. Couples are randomized 1:1 to the experimental treatment (START Together) or treatment as usual (referrals to the local clinic to support ART adherence or any other HIV-related care). START Together is a 5-session intervention based in cognitive-behavioral couple therapy, which is a skill-based intervention focusing on communication and problem-solving skills, and Life Steps, a problem-solving intervention identifying barriers and solutions to medication adherence. Couples are assessed at baseline, post-treatment (8 weeks post-randomization), and follow-up (12 weeks post-randomization). Conclusion: This study will provide preliminary implementation and efficacy data on whether this novel approach has potential to improve women and men's HIV and healthcare-related needs.

Protecting the Kidneys: Update on Therapies to Treat Diabetic Nephropathy.

This article provides an update on pharmacotherapy for diabetic nephropathy. ACE inhibitor or angiotensin 2 receptor blocker therapy is a standard of care for hypertension management in people with diabetes and albuminuria. Additionally, recent trials have elucidated the roles of additional therapeutic agents, including the sodium-glucose cotransporter 2 inhibitors, glucagon-like peptide 1 receptor agonists, and the recently approved mineralocorticoid receptor antagonist finerenone, in the treatment of chronic kidney disease in people with type 2 diabetes. This article provides an evidence-based review of therapies that may delay the progression of kidney disease in this population, including discussion of recent outcomes trials.

Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial.

BACKGROUND: Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention. METHODS: Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems. RESULTS: Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040]. CONCLUSION: Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

Patient and provider perceptions of a peer-delivered intervention ('Khanya') to improve anti-retroviral adherence and substance use in South Africa: a mixed methods analysis.

Background: Despite a high prevalence of problematic substance use among people living with HIV in South Africa, there remains limited access to substance use services within the HIV care system. To address this gap, our team previously developed and adapted a six-session, peer-delivered problem-solving and behavioral activation-based intervention (Khanya) to improve HIV medication adherence and reduce substance use in Cape Town. This study evaluated patient and provider perspectives on the intervention to inform implementation and future adaptation. Methods: Following intervention completion, we conducted semi-structured individual interviews with patients (n = 23) and providers (n = 9) to understand perspectives on the feasibility, acceptability, and appropriateness of Khanya and its implementation by a peer. Patients also quantitatively ranked the usefulness of individual intervention components (problem solving for medication adherence 'Life-Steps', behavioral activation, mindfulness training, and relapse prevention) at post-treatment and six months follow-up, which we triangulated with qualitative feedback to examine convergence and divergence across methods. Results: Patients and providers reported high overall acceptability, feasibility, and appropriateness of Khanya, although there were several feasibility challenges. Mindfulness and Life-Steps were identified as particularly acceptable, feasible, and appropriate components by patients across methods, whereas relapse prevention strategies were less salient. Behavioral activation results were less consistent across methods. Conclusions: Findings underscore the importance of examining patients' perspectives on specific intervention components within intervention packages. While mindfulness training and peer delivery models were positively perceived by consumers, they are rarely used within task-shared behavioral interventions in low- and middle-income countries.

Use of Angiotensin-Converting Enzyme Inhibitors/Angiotensin Receptor Blockers and Acute Kidney Disease after an Episode of AKI: A Multicenter Prospective Cohort Study.

BACKGROUND: Persistence of acute kidney disease (AKD) after an episode of acute kidney injury (AKI) is associated with adverse outcomes. Multiple factors contribute to AKD after AKI, but the role of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB) remains controversial. We examined if acute exposure to an ACEI/ARB associates with persistent AKD in survivors of AKI. METHODS: Multicenter prospective cohort study of patients whose hospitalization was complicated by AKI and who attended specialized AKI follow-up clinics between 2013 and 2018. Acute exposure was defined as ACEI/ARB exposure for ≥48 h before or during the AKI episode. The primary outcome was AKD (serum creatinine ≥1.5 times above pre-AKI baseline) at the first clinic visit. We used multivariable logistic regression to adjust for potential confounders. RESULTS: We included 345 survivors of AKI, 112 with persistent AKD at the first outpatient visit. Among 163 patients who were prescribed an ACEI/ARB before hospitalization, only 23% were discharged on an ACEI/ARB. There was no difference in the rate of AKD in patients discharged versus not discharged on an ACEI/ARB (12.5 vs. 15.0%, p = 0.530). Of the patients with AKD, 22 (19.6%) patients had acute ACEI/ARB exposure during the hospitalization. In fully adjusted models, acute exposure to an ACEI/ARB was not associated with AKD at the time of first clinic visit (median [interquartile range] 33 [18-54] days from hospital discharge). CONCLUSION: Acute exposure to an ACEI/ARB before or during an episode of AKI was not associated with persistent AKD at the time of first clinic visit suggesting that the receipt of such agents does not impede kidney recovery following AKI. Contrary to prevailing recommendations and current practice, the continued administration of an ACEI/ARB during an episode of AKI or initiation of these agents prior to discharge may be safe.

Prevalence, Risk Factors, Treatment, and Overall Impact of BK Viremia on Kidney Transplantation.

BK viremia (BKV) is a recognized and potentially serious problem in renal transplantation. The risk factors and the impact of BKV on renal allograft and patient survival are controversial. This study reports an 8-year, single-center experience on the prevalence, risk factors, and outcomes of BKV in kidney transplant recipients. This is a retrospective analysis of all patients who received a kidney transplant at the University of Kentucky and had BK viral titers available from 2009 to 2017. BKV was defined by a polymerase chain reaction viral load of ≥ 10,000 copies per mL. Demographic, clinical, and laboratory data generated during routine outpatient follow up and inpatients records were collected. Independent risk factors for BKV were determined using uni- and multivariate analysis. Graft and patient survival was compared using Kaplan-Meier analysis, and the severity of polyomavirus nephropathy on biopsy was scored using the Banff 2017 classification. We identified 122 BK positive (19%) and 527 BK negative (81%) patients. BKV developed after a median of 115 days (range, 80-249 days) following kidney transplantation. The 1-, 5-, and 10-year graft survival was 97%, 75%, and 33% in the BKV group and 96%, 85%, and 71% in the BK negative group, respectively. Likewise, the 1-, 5-, and 10-year patient survival was 98%, 84%, and 52% in the BKV group and 98%, 92%, and 84% in the BK negative group. Male sex, age at transplantation, maintenance steroids, and alemtuzumab induction were associated with developing BKV in the multivariate analysis. We concluded that BKV is not uncommon after renal transplantation. The determinants for BKV are male sex, older transplant recipients, and maintenance steroids. BKV adversely affected graft and patient survival. A unified approach for BKV and polyomavirus nephropathy treatment is needed.