Prevalence and Correlates of Substance Use Among Youth Living with HIV in Fishing Communities in Uganda.

Alcohol and drug use (ADU) poses a significant barrier to optimal HIV treatment outcomes for adolescents and youths living with HIV (AYLHIV). We aimed to investigate the prevalence and correlates of ADU among ALHIV in Ugandan fishing communities, areas characterized by high HIV and poverty rates. AYLHIV aged 18-24, who knew they were HIV-positive, were selected from six HIV clinics. Substance use was determined through self-report in the last 12 months and urine tests for illicit substances. Utilizing a socioecological framework, the study structured variables into a hierarchical logistic regression analysis to understand the multi-layered factors influencing ADU. Self-reported past 12 months substance use was 42%, and 18.5% of participants had a positive urine test for one or more substances, with alcohol, benzodiazepines, and marijuana being the most commonly used. With the addition of individual-level socio-demographics, indicators of mental health functioning, interpersonal relationships, and community factors, the logistic regression analysis revealed greater exposure to adverse childhood experiences increased the odds of substance use (Odds Ratio [OR] = 1.24; 95% Confidence Interval [CI]: 1.03-1.55). Additionally, exposure to alcohol advertisements at community events significantly raised the odds of substance use (OR = 3.55; 95% CI: 1.43-8.83). The results underscore the high prevalence among AYLHIV and emphasize the need for comprehensive interventions targeting individual (e.g., life skills education and mental health supports), interpersonal (e.g., peer support and family-based interventions), community (e.g., community engagement programs, restricted alcohol advertisements and illicit drug access), and policies (e.g., integrated care models and a national drug use strategy), to address ADU.

Intersectional HIV- and Depression-Related Stigma Among People with HIV Entering HIV Care in Cameroon.

Mental health-related stigma is a prominent barrier to improved mental health outcomes globally and may be particularly harmful to populations with other stigmatized identities. We aimed to understand intersectional depression- and HIV-related stigma among people with HIV (PWH) entering HIV care in Cameroon. Using baseline data from a cohort of PWH entering HIV care in Cameroon between 2019 and 2020, we characterized depression- and HIV-related stigma in the population overall and by sociodemographic sub-group. We also explored substantively meaningful variation in stigma endorsement by depressive symptom severity (Patient Health Questionnaire-9 [PHQ-9]) and causal attribution of depression. Among those with elevated depressive symptoms (PHQ-9 scores > 4), we estimated the association between stigma type and depressive symptom severity using binomial regression. Among 398 participants, 49% endorsed low HIV- and depression-related stigma (N = 195), 10% endorsed high HIV- and depression-related stigma (N = 38), 29% endorsed high depression-related stigma only (N = 116), and 12% endorsed high HIV-related stigma only (N = 49). Respondents with and without heightened depressive symptoms commonly believed depressive symptoms were caused by HIV (N = 140; 32.9%). Among those with elevated depressive symptoms, the prevalence of moderate to severe symptoms was higher among those endorsing high HIV-related stigma only (prevalence ratio 1.55; 95% confidence interval: 1.01, 2.37) compared to those reporting low HIV- and depression-related stigma. HIV- and depression-related stigma are both common among PWH entering HIV care in Cameroon. The consistent association between HIV-related stigma and poor psychosocial well-being among people with HIV necessitates the urgent scale-up of evidence-based HIV-related stigma interventions specifically.

Organizing the dissemination and implementation field: who are we, what are we doing, and how should we do it?

Two decades into its tenure as a field, dissemination and implementation (D&I) scientists have begun a process of self-reflection, illuminating a missed opportunity to bridge the gap between research and practice-one of the field's foundational objectives. In this paper, we, the authors, assert the research-to-practice gap has persisted, in part due to an inadequate characterization of roles, functions, and processes within D&I. We aim to address this issue, and the rising tension between D&I researchers and practitioners, by proposing a community-centered path forward that is grounded in equity.We identify key players within the field and characterize their unique roles using the translational science spectrum, a model originally developed in the biomedical sciences to help streamline the research-to-practice process, as a guide. We argue that the full translational science spectrum, from basic science research, or "T0," to translation to community, or "T4," readily applies within D&I and that in using this framework to clarify roles, functions, and processes within the field, we can facilitate greater collaboration and respect across the entire D&I research-to-practice continuum. We also highlight distinct opportunities (e.g., changes to D&I scientific conference structures) to increase regular communication and engagement between individuals whose work sits at different points along the D&I translational science spectrum that can accelerate our efforts to close the research-to-practice gap and achieve the field's foundational objectives.

An mHealth Intervention to Address Depression and Improve Antiretroviral Therapy Adherence Among Youths Living With HIV in Uganda: Protocol for a Pilot Randomized Controlled Trial.

BACKGROUND: People living with HIV often struggle with mental health comorbidities that lower their antiretroviral therapy (ART) adherence. There is growing evidence that depression treatment may improve ART adherence and result in improved HIV outcomes. Given that mental health services are severely underequipped in low-resource settings, including in Uganda, new solutions to increase access to mental health care and close the treatment gap are urgently needed. This protocol paper presents the Suubi-Mhealth study, which proposed to develop a mobile health (mHealth) intervention for use among Ugandan youths (14-17 years) with comorbid HIV and depression, taking into account their unique contextual, cultural, and developmental needs. OBJECTIVE: The proposed study is guided by the following objectives: (1) to develop and iteratively refine an intervention protocol for Suubi-Mhealth based on formative work to understand the needs of youths living with HIV; (2) to explore the feasibility and acceptability of Suubi-Mhealth on a small scale to inform subsequent refinement; (3) to test the preliminary impact of Suubi-Mhealth versus a waitlist control group on youths' outcomes, including depression and treatment adherence; and (4) to examine barriers and facilitators for integrating Suubi-Mhealth into health care settings. METHODS: Youths will be eligible to participate in the study if they are (1) 14-17 years of age, (2) HIV-positive and aware of their status, (3) receiving care and ART from one of the participating clinics, and (4) living within a family. The study will be conducted in 2 phases. In phase 1, we will conduct focus group discussions with youths and health care providers, for feedback on the proposed intervention content and methods, and explore the feasibility and acceptability of the intervention. In phase II, we will pilot-test the preliminary impact of the intervention on reducing depression and improving ART adherence. Assessments will be conducted at baseline, 1-, 2-, and 6-months post intervention completion. RESULTS: Participant recruitment for phase 1 is completed. Youths and health care providers participated in focus group discussions to share their feedback on the proposed Suubi-Mhealth intervention content, methods, design, and format. Transcription and translation of focus group discussions have been completed. The team is currently developing Suubi-Mhealth content based on participants' feedback. CONCLUSIONS: This study will lay important groundwork for several initiatives at the intersection of digital therapeutics, HIV treatment, and mental health, especially among sub-Saharan African youths, as they transition through adolescence and into adult HIV care settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT05965245; https://clinicaltrials.gov/study/NCT05965245. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/54635.

Instrumental variables for implementation science: exploring context-dependent causal pathways between implementation strategies and evidence-based interventions.

BACKGROUND: The impact of both implementation strategies (IS) and evidence-based interventions (EBI) can vary across contexts, and a better understanding of how and why this occurs presents fundamental but challenging questions that implementation science as a field will need to grapple with. We use causal epidemiologic methods to explore the mechanisms of why sharp distinctions between implementation strategies (IS) and efficacy of an evidence-based intervention (EBI) may fail to recognize that the effect of an EBI can be deeply intertwined and dependent on the context of the IS leading to its uptake. METHODS: We explore the use of instrumental variable (IV) analyses as a critical tool for implementation science methods to isolate three relevant quantities within the same intervention context when exposure to an implementation strategy is random: (1) the effect of an IS on implementation outcomes (e.g., uptake), (2) effect of EBI uptake on patient outcomes, and (3) overall effectiveness of the IS (i.e., ~ implementation*efficacy). We discuss the mechanisms by which an implementation strategy can alter the context, and therefore effect, of an EBI using the underlying IV assumptions. We illustrate these concepts using examples of the implementation of new ART initiation guidelines in Zambia and community-based masking programs in Bangladesh. RESULTS: Causal questions relevant to implementation science are answered at each stage of an IV analysis. The first stage assesses the effect of the IS (e.g., new guidelines) on EBI uptake (e.g., same-day treatment initiation). The second stage leverages the IS as an IV to estimate the complier average causal effect (CACE) of the EBI on patient outcomes (e.g., effect of same-day treatment initiation on viral suppression). The underlying assumptions of CACE formalize that the causal effect of EBI may differ in the context of a different IS because (1) the mechanisms by which individuals uptake an intervention may differ and (2) the subgroup of individuals who take up an EBI may differ. IV methods thus provide a conceptual framework for how IS and EBIs are linked and that the IS itself needs to be considered a critical contextual determinant. Moreover, it also provides rigorous methodologic tools to isolate the effect of an IS, EBI, and combined effect of the IS and EBI. DISCUSSION: Leveraging IV methods when exposure to an implementation strategy is random helps to conceptualize the context-dependent nature of implementation strategies, EBIs, and patient outcomes. IV methods formalize that the causal effect of an EBI may be specific to the context of the implementation strategy used to promote uptake. This integration of implementation science concepts and theory with rigorous causal epidemiologic methods yields novel insights and provides important tools for exploring the next generation of questions related to mechanisms and context in implementation science.