Depressive Symptoms,HIV Medication Adherence,and HIV Clinical Outcomes in Tanzania: A Prospective,Observational Study

Depressive symptoms have been shown to independently affect both antiretroviral therapy (ART) adherence and HIV clinical outcomes in high-income countries. We examined the prospective relationship between depressive symptoms and adherence, virologic failure, and suppressed immune function in people living with HIV/AIDS in Tanzania. Data from 403 study participants who were on stable ART and engaged in HIV clinical care were analyzed. We assessed crude and adjusted associations of depressive symptoms and ART adherence, both at baseline and at 12 months, using logistic regression. We used logistic generalized estimating equations to assess the association and 95% confidence intervals (CI) between depressive symptoms and both virologic failure and suppressed immune function. Ten percent of participants reported moderate or severe depressive symptoms at baseline and 31% of participants experienced virologic failure (>150 copies/ml) over two years. Depressive symptoms were associated with greater odds of reported medication nonadherence at both baseline (Odds Ratio [OR] per 1-unit increase  = 1.18, 95% CI [1.12, 1.24]) and 12 months (OR  = 1.08, 95% CI [1.03, 1.14]). By contrast, increases in depressive symptom score were inversely related to both virologic failure (OR = 0.93, 95% CI [0.87, 1.00]) and immune system suppression (OR = 0.88, 95% CI [0.79, 0.99]), though the association between depressive symptoms and clinical outcomes was less precise than for the association with nonadherence. Findings indicate a positive association between depressive symptoms and nonadherence, and also an inverse relationship between depressive symptoms and clinical outcomes, possibly due to informative loss to follow-up.     

Rising Levels of HIV Infection in Older Adults in Eastern Zimbabwe

BackgroundWith the scale-up of antiretroviral treatment across Africa, many people are living longer with HIV. Understanding the ageing of the HIV cohort and sexual behaviour among older adults are important for appropriately responding to the changing demographics of people living with HIV.MethodsWe used data from a large population-based open cohort in eastern Zimbabwe to examine HIV prevalence trends and incidence among those aged 45 years and older. Five survey rounds have been completed between 1998 and 2011. Incidence was analysed using midpoint between last negative and first positive HIV test.ResultsAcross the survey rounds, 13,071 individuals were followed for 57,676 person years. While HIV prevalence among people aged 15–44 has fallen across the five rounds, HIV prevalence among those aged 45–54 has increased since the 2006–08 survey round. In the 2009–11 round, HIV prevalence among men aged 45–54 was 23.4% compared to 11.0% among those aged 15–44. HIV positive people aged 45–54 now represent more than 20% of all those living with HIV in Manicaland. Among those aged 45 years and older, there were 85 seroconversions in 11,999 person years for an HIV incidence of 0.708 per 100 person years. Analysis of cohort data and assessment of behavioural risk factors for HIV infection among older people shows significantly lower levels of condom use among older adults and a number of seroconversions past the age of 50.ConclusionsThe cohort of people living with HIV is ageing in Zimbabwe and the behaviour of older adults puts them at risk of HIV infection. Older adults must be included in both HIV prevention and treatment programs.     

The Impacts of Migraine among Outpatients with Major Depressive Disorder at a Two-Year Follow-Up

BackgroundNo study has investigated the impacts of migraine on depression, anxiety, and somatic symptoms and remission at the two-year follow-up point among patients with major depressive disorder (MDD). This study aimed to investigate the above issues.MethodsPsychiatric outpatients with MDD recruited at baseline were investigated at a two-year follow-up (N = 106). The Hamilton Depression Rating Scale, Hospital Anxiety and Depression Scale, and Depression and Somatic Symptoms Scale were used. Migraine was diagnosed according to the International Classification of Headache Disorders, 2^nd edition. The patients were divided into no migraine, inactive migraine, and active migraine subgroups. Multiple logistic regressions were used to investigate the significant factors related to full remission of depression.ResultsAmong patients without pharmacotherapy at the follow-up, patients with active migraine had significantly greater severities of anxiety and somatic symptoms as compared with patients without migraine; moreover, patients with active migraine had the lowest improvement percentage and full remission rate. There were no significant differences in depression, anxiety, and somatic symptoms between patients with inactive migraine and those without migraine. Active headache at follow-up was a significant factor related to a lower full remission rate.ConclusionsActive headache at follow-up was associated with a lower rate of full remission and more residual anxiety and somatic symptoms at follow-up among patients with migraine. Physicians should integrate a treatment plan for depression and migraine for the treatment of patients with MDD.     

Cross-Culture Validation of the HIV/AIDS Stress Scale: The Development of a Revised Chinese Version

BackgroundBeing HIV-infected is a stressful experience for many individuals. To assess HIV-related stress in the Chinese context, a measure with satisfied psychometric properties is yet underdeveloped. This study aimed to examine the psychometric characteristics of a simplified Chinese version of the HIV/AIDS Stress Scale (SS-HIV) among people living with HIV/AIDS in central China.MethodA total of 667 people living with HIV (92% were male) were recruited from March 1^st 2014 to August 31^th 2015 by consecutive sampling. A standard questionnaire package containing the Chinese HIV/AIDS Stress Scale (CSS-HIV), the Chinese Patient Health Questionnaire-9 (PHQ-9), and the Chinese Generalized Anxiety Disorder Scale (GAD-7) were administered to all participants, and 38 of the participants were selected randomly to be re-tested in four weeks after the initial testing.ResultsOur data supported that a revised 17-item CSS-HIV had adequate psychometric properties. It consisted of 3 factors: emotional stress (6 items), social stress (6 items) and instrumental stress (5 items). The overall Cronbach’s α was 0.906, and the test-retest reliability coefficient was 0.832. The revised CSS-HIV was significantly correlated with the number of HIV-related symptoms, as well as scores on the PHQ-9 and GAD-7, indicating acceptable concurrent validity.ConclusionThe 17-item Chinese version of the SS-HIV has potential research and clinical utility in identifying important stressors among the Chinese HIV-infected population and in understanding the effects of stress on adjustment to HIV.     

Validation of Six Short and Ultra-short Screening Instruments for Depression for People Living with HIV in Ontario: Results from the Ontario HIV Treatment Network Cohort Study

Objective

Major depression affects up to half of people living with HIV. However, among HIV-positive patients, depression goes unrecognized 60–70% of the time in non-psychiatric settings. We sought to evaluate three screening instruments and their short forms to facilitate the recognition of current depression in HIV-positive patients attending HIV specialty care clinics in Ontario.

Methods

A multi-centre validation study was conducted in Ontario to examine the validity and accuracy of three instruments (the Center for Epidemiologic Depression Scale [CESD₂₀], the Kessler Psychological Distress Scale [K₁₀], and the Patient Health Questionnaire depression scale [PHQ₉]) and their short forms (CESD₁₀, K₆, and PHQ₂) in diagnosing current major depression among 190 HIV-positive patients in Ontario. Results from the three instruments and their short forms were compared to results from the gold standard measured by Mini International Neuropsychiatric Interview (the “M.I.N.I.”).

Results

Overall, the three instruments identified depression with excellent accuracy and validity (area under the curve [AUC]>0.9) and good reliability (Kappa statistics: 0.71–0.79; Cronbach’s alpha: 0.87–0.93). We did not find that the AUCs differed in instrument pairs (p-value>0.09), or between the instruments and their short forms (p-value>0.3). Except for the PHQ_2, the instruments showed good-to-excellent sensitivity (0.86–1.0) and specificity (0.81–0.87), excellent negative predictive value (>0.90), and moderate positive predictive value (0.49–0.58) at their optimal cut-points.

Conclusion

Among people in HIV care in Ontario, Canada, the three instruments and their short forms performed equally well and accurately. When further in-depth assessments become available, shorter instruments might find greater clinical acceptance. This could lead to clinical benefits in fast-paced speciality HIV care settings and better management of depression in HIV-positive patients.     

Factors Associated with HIV Prevalence and HIV Testing in Sierra Leone: Findings from the 2008 Demographic Health Survey

BackgroundThe Sierra Leone Demographic Health Survey 2008 found an HIV prevalence of 1.5%. This study investigates associations with HIV infection and HIV testing.MethodsHouseholds were selected using stratified multi-stage sampling. In all selected households women aged 15–49 were eligible. In every second household men aged 15–59 were also eligible. Participants were asked to consent for anonymous HIV testing. All participants interviewed and tested were analysed. Multiple logistic regression identified associations with HIV infection, undiagnosed infection and with ever having a voluntary HIV test among sexually active participants.ResultsOf 7495 invited 86% (6,475) agreed to an interview and HIV test. Among 96 HIV positive participants, 78% had never taken a voluntary HIV test so were unaware of their serostatus, and 86% were sexually active in the last 12 months among whom 96% did not use a condom at last intercourse. 11% of all participants had previously voluntarily tested. Among women who had tested, 60% did so in antenatal care. We found that those living in an urban area, and those previously married, were more likely to be HIV infected. Voluntary HIV testing was more common in those aged 25–44, living in an urban area, females, having secondary or higher education, having first sexual intercourse at age 17 years or older, and using condoms at last sex. Although 82% of men and 69% of women had heard of HIV, only 35% and 29% respectively had heard of antiretroviral therapy.ConclusionsThe HIV prevalence in Sierra Leone has been stable. HIV testing, however, is uncommon and most infected individuals are unaware of their serostatus. This could allow the epidemic to escalate as individuals with undiagnosed infection are unlikely to change their behaviour or access treatment. Improving knowledge and increasing testing need to remain central to HIV prevention interventions in Sierra Leone.     

The Associations of Psychological Stress with Depressive and Anxiety Symptoms among Chinese Bladder and Renal Cancer Patients: The Mediating Role of Resilience

BackgroundThe prevalence of depressive and anxiety symptoms and their associated factors in bladder and renal cancer patients are not well evaluated in China. Given the growing attention to positive psychological constructs in the field of oncology, it is necessary to explore the effects of these constructs on depressive and anxiety symptoms. This study aims to explore the associations of psychological stress with depressive and anxiety symptoms among Chinese bladder and renal cancer patients and the mediating role of resilience in these relationships.MethodsA cross-sectional study was conducted at the First Affiliated Hospital of China Medical University in Liaoning province. 327 bladder cancer patients and 268 renal cancer patients completed questionnaires on demographic variables, the Center for Epidemiologic Studies Depression Scale, Zung Self-Rating Anxiety Scale, Resilience Scale-14, and Perceived Stress Scale-10 during the period from July 2013 to July 2014. Hierarchical linear regression analyses were performed to explore the mediating role of resilience.ResultsThe prevalence of depressive and anxiety symptoms was 78.0% and 71.3% in bladder cancer patients, and 77.6% and 68.3% in renal cancer patients. Psychological stress was positively related to depressive and anxiety symptoms, while resilience was negatively related to these symptoms. Resilience partially mediated the relations of psychological stress with depressive and anxiety symptoms.ConclusionsThe high prevalence of depressive and anxiety symptoms among Chinese bladder and renal cancer patients should receive more attention from medical institutions and government agencies. In addition to reducing depressive and anxiety symptoms, resilience development should be included in depression and anxiety prevention and treatment strategies in China.     

Frequency of and Risk Factors for Depression among Participants in the Swiss HIV Cohort Study (SHCS)

Objectives

We studied the incidence and prevalence of, and co-factors for depression in the Swiss HIV Cohort Study.

Methods

Depression-specific items were introduced in 2010 and prospectively collected at semiannual cohort visits. Clinical, laboratory and behavioral co-factors of incident depression among participants free of depression at the first two visits in 2010 or thereafter were analyzed with Poisson regression. Cumulative prevalence of depression at the last visit was analyzed with logistic regression.

Results

Among 4,422 participants without a history of psychiatric disorders or depression at baseline, 360 developed depression during 9,348 person-years (PY) of follow-up, resulting in an incidence rate of 3.9 per 100 PY (95% confidence interval (CI) 3.5–4.3). Cumulative prevalence of depression during follow-up was recorded for 1,937/6,756 (28.7%) participants. Incidence and cumulative prevalence were higher in injection drug users (IDU) and women. Older age, preserved work ability and higher physical activity were associated with less depression episodes. Mortality (0.96 per 100 PY, 95% CI 0.83–1.11) based upon 193 deaths over 20,102 PY was higher among male IDU (2.34, 1.78–3.09), female IDU (2.33, 1.59–3.39) and white heterosexual men (1.32, 0.94–1.84) compared to white heterosexual women and homosexual men (0.53, 0.29–0.95; and 0.71, 0.55–0.92). Compared to participants free of depression, mortality was slightly elevated among participants with a history of depression (1.17, 0.94–1.45 vs. 0.86, 0.71–1.03, P = 0.033). Suicides (n = 18) did not differ between HIV transmission groups (P = 0.50), but were more frequent among participants with a prior diagnosis of depression (0.18 per 100 PY, 95%CI 0.10–0.31; vs. 0.04, 0.02–0.10; P = 0.003).

Conclusions

Depression is a frequent co-morbidity among HIV-infected persons, and thus an important focus of care.     

HIV Prevention in Care and Treatment Settings: Baseline Risk Behaviors among HIV Patients in Kenya,Namibia, and Tanzania

HIV care and treatment settings provide an opportunity to reach people living with HIV/AIDS (PLHIV) with prevention messages and services. Population-based surveys in sub-Saharan Africa have identified HIV risk behaviors among PLHIV, yet data are limited regarding HIV risk behaviors of PLHIV in clinical care. This paper describes the baseline sociodemographic, HIV transmission risk behaviors, and clinical data of a study evaluating an HIV prevention intervention package for HIV care and treatment clinics in Africa. The study was a longitudinal group-randomized trial in 9 intervention clinics and 9 comparison clinics in Kenya, Namibia, and Tanzania (N = 3538). Baseline participants were mostly female, married, had less than a primary education, and were relatively recently diagnosed with HIV. Fifty-two percent of participants had a partner of negative or unknown status, 24% were not using condoms consistently, and 11% reported STI symptoms in the last 6 months. There were differences in demographic and HIV transmission risk variables by country, indicating the need to consider local context in designing studies and using caution when generalizing findings across African countries. Baseline data from this study indicate that participants were often engaging in HIV transmission risk behaviors, which supports the need for prevention with PLHIV (PwP).

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01256463","term_id":"NCT01256463"}}NCT01256463     

A Descriptive Analysis of HIV Prevalence,HIV Service Uptake,and HIV-Related Risk Behaviour among Patients Attending a Mental Health Clinic in Rural Malawi

Background

Human immunodeficiency virus (HIV) and mental illness are interlinked health problems; mental illness may pose a risk for contracting HIV and HIV-positive individuals are at higher risk of mental illness. However, in countries with high HIV prevalence, the main focus of HIV-related health programmes is usually on prevention and treatment of somatic complications of HIV, and mental illness is not given high priority. We examined HIV prevalence, uptake of HIV services, and HIV-related risk behaviour among people attending a mental health clinic in rural Malawi.

Methodology

Semi-structured interviews were performed with patients capable to consent (94%), and with those accompanied by a capable caregiver who consented. HIV counselling and testing was offered to participants.

Findings

Among 174 participants, we collected 162 HIV test results (91%). HIV prevalence was 14.8%. Women were three times as likely to be HIV-positive compared to men. Two-thirds of participants reported having been tested for HIV prior to this study. The uptake of HIV-services among HIV-positive patients was low: 35% did not use recommended prophylactic therapy and 44% of patients not receiving antiretroviral treatment (ART) had never been assessed for ART eligibility. The reported rate of sexual activity was 61%, and 9% of sexually active participants had multiple partners. Inconsistent condom use with stable (89%) and occasional (79%) sexual partners, and absence of knowledge of the HIV status of those partners (53%, 63%) indicate high levels of sexual risk behaviour.

Conclusions

HIV-prevalence among persons attending the clinic, particularly men, was lower than among the general population in a population survey. The rate of HIV testing was high, but there was low uptake of preventive measures and ART. This illustrates that HIV-positive individuals with mental illness or epilepsy constitute a vulnerable population. HIV programmes should include those with neuropsychiatric illness.     

Depression,Anxiety and Glucose Metabolism in the General Dutch Population: The New Hoorn Study

Background

There is a well recognized association between depression and diabetes. However, there is little empirical data about the prevalence of depressive symptoms and anxiety among different groups of glucose metabolism in population based samples. The aim of this study was to determine whether the prevalence of increased levels of depression and anxiety is different between patients with type 2 diabetes and subjects with impaired glucose metabolism (IGM) and normal glucose metabolism (NGM).

Methodology/Principal Findings

Cross-sectional data from a population-based cohort study of 2667 residents, 1261 men and 1406 women aged 40–65 years from the Hoorn region, the Netherlands. Depressive symptoms and anxiety were measured using the Centre for Epidemiologic Studies Depression Scale (CES-D, score ≥16) and the Hospital Anxiety and Depression Scale – Anxiety Subscale (HADS-A, score ≥8), respectively. Glucose metabolism status was determined by oral glucose tolerance test. In the total study population the prevalence of depressive symptoms and anxiety for the NGM, IGM and type 2 diabetes were 12.5, 12.2 and 21.0% (P = 0.004) and 15.0, 15.3 and 19.9% (p = 0.216), respectively. In men, the prevalence of depressive symptoms was 7.7, 9.5 and 19.6% (p<0.001), and in women 16.4, 15.8 and 22.6 (p = 0.318), for participants with NGM, IGM and type 2 diabetes, respectively. Anxiety was not associated with glucose metabolism when stratified for sex. Intergroup differences (NGM vs. IGM and IGM vs. type 2 diabetes) revealed that higher prevalences of depressive symptoms are mainly manifested in participants with type 2 diabetes, and not in participants with IGM.

Conclusions

Depressive symptoms, but not anxiety are associated with glucose metabolism. This association is mainly determined by a higher prevalence of depressive symptoms in participants with type 2 diabetes and not in participants with IGM.     

Poverty,Food Insufficiency and HIV Infection and Sexual Behaviour among Young Rural Zimbabwean Women

Background

Despite a recent decline, Zimbabwe still has the fifth highest adult HIV prevalence in the world at 14.7%; 56% of the population are currently living in extreme poverty.

Design

Cross-sectional population-based survey of 18–22 year olds, conducted in 30 communities in south-eastern Zimbabwe in 2007.

Objective

To examine whether the risk of HIV infection among young rural Zimbabwean women is associated with socio-economic position and whether different socio-economic domains, including food sufficiency, might be associated with HIV risk in different ways.

Methods

Eligible participants completed a structured questionnaire and provided a finger-prick blood sample tested for antibodies to HIV and HSV-2. The relationship between poverty and HIV was explored for three socio-economic domains: ability to afford essential items; asset wealth; food sufficiency. Analyses were performed to examine whether these domains were associated with HIV infection or risk factors for infection among young women, and to explore which factors might mediate the relationship between poverty and HIV.

Results

2593 eligible females participated in the survey and were included in the analyses. Overall HIV prevalence among these young females was 7.7% (95% CI: 6.7–8.7); HSV-2 prevalence was 11.2% (95% CI: 9.9–12.4). Lower socio-economic position was associated with lower educational attainment, earlier marriage, increased risk of depression and anxiety disorders and increased reporting of higher risk sexual behaviours such as earlier sexual debut, more and older sexual partners and transactional sex. Young women reporting insufficient food were at increased risk of HIV infection and HSV-2.

Conclusions

This study provides evidence from Zimbabwe that among young poor women, economic need and food insufficiency are associated with the adoption of unsafe behaviours. Targeted structural interventions that aim to tackle social and economic constraints including insufficient food should be developed and evaluated alongside behaviour and biomedical interventions, as a component of HIV prevention programming and policy.     

Reliable change in depression during behavioral weight loss treatment among women with major depression

Objective: Although behavioral weight loss interventions generally have been shown to improve depressive symptoms, little is known as to whether some people with major depressive disorder experience worsening of depression during a weight loss intervention. Design and Methods: Rates and predictors of change in depression symptoms among 148 obese women with major depressive disorder who participated in a trial comparing depression treatment plus behavioral weight loss treatment (Behavioral Activation; BA) to behavioral weight loss treatment alone (Lifestyle Intervention; LI) were examined. A statistically reliable change in depression was calculated as ≥9 points on the Beck Depression Inventory in this sample. Results: At 6 months, 73% of participants in BA and 54% of participants in LI showed reliable improvement in depression symptoms and 1.5% of participants in BA and 1.3% of participants in LI showed reliable worsening in depression symptoms. Rates of reliable change were similar at 12 months. Participants who experienced reliable improvement in depression lost significantly more weight than those who did not in both conditions. In the LI condition, baseline psychiatric variables and change in physical activity during treatment were also related to reliable improvement in depression. Conclusion: No evidence for an iatrogenic effect of behavioral weight loss treatment on depressive symptoms among obese women with major depressive disorder was detected; rather, behavioral weight loss treatment appears to be associated with significant concurrent improvement in depression. Even greater rates of reliable improvement were observed when depression treatment was added to weight loss treatment.     

Increased HIV Testing among Men Who Have Sex with Men from 2008 to 2012, Nanjing,China

BackgroundHIV testing is the first point of HIV treatment entry for HIV-infected individuals and an avenue to engage persons at risk in prevention. In China, where the prevalence of HIV among men who have sex with men (MSM) has been rising over the last decade, uptake of HIV testing has been low.MethodsWe examined changes in HIV testing in the preceding 12 months through two cross-sectional surveys conducted among MSM in Nanjing, Jiangsu province, China in 2008 and 2012. Respondent-driven sampling (RDS) was used to recruit participants. Questionnaire interviews and venous blood were collected to measure HIV testing, risk behaviors, and prevalence of HIV, syphilis, and HSV-2.ResultsA total of 430 and 589 MSM were surveyed in 2008 and 2012, respectively, with comparable samples in each round with respect to demographic characteristics. HIV testing in the past 12 months increased significantly from 20.1% (95% CI 13.3–26.8) in 2008 to 46.0% (95% CI 39.3–51.4, p < 0.001) in 2012. HIV prevalence was stable, at 6.6% (95% CI 2.5–11.3) in 2008 and 10.1% (95% CI 6.6–13.9, p = 0.240) in 2012, as was syphilis (14.3% in 2008 vs. 9.9% in 2012, p = 0.240). HSV-2 prevalence (18.6% in 2008 vs. 10.2% in 2012, p = 0.040) and self-reported STI in the last year (24.3% in 2008 vs. 14.3% in 2012, p = 0.020) significantly decreased. Changes in reported sexual behaviors were mixed and the profiles of who did and did not test varied between 2008 and 2012.ConclusionsHIV testing uptake more than doubled among MSM in Nanjing from 2008 to 2012 –a period of massive promotion and scale up of testing programs for MSM. However, additional efforts are still needed to further increase the proportion of men being not only tested but also undergoing repeat testing if they engage in continued risk taking behavior.     

Peer-led counselling with problem discussion therapy for adolescents living with HIV in Zimbabwe: A cluster-randomised trial

BackgroundAdolescents living with HIV have poor virological suppression and high prevalence of common mental disorders (CMDs). In Zimbabwe, the Zvandiri adolescent peer support programme is effective at improving virological suppression. We assessed the effect of training Zvandiri peer counsellors known as Community Adolescent Treatment Supporters (CATS) in problem-solving therapy (PST) on virological suppression and mental health outcomes.Methods and findingsSixty clinics were randomised 1:1 to either normal Zvandiri peer counselling or a peer counsellor trained in PST. In January to March 2019, 842 adolescents aged 10 to 19 years and living with HIV who screened positive for CMDs were enrolled (375 (44.5%) male and 418 (49.6%) orphaned of at least one parent). The primary outcome was virological nonsuppression (viral load ≥1,000 copies/mL). Secondary outcomes were symptoms of CMDs measured with the Shona Symptom Questionnaire (SSQ ≥8) and depression measured with the Patient Health Questionnaire (PHQ-9 ≥10) and health utility score using the EQ-5D. The adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated using logistic regression adjusting for clinic-level clustering. Case reviews and focus group discussions were used to determine feasibility of intervention delivery.At baseline, 35.1% of participants had virological nonsuppression and 70.3% had SSQ≥8. After 48 weeks, follow-up was 89.5% for viral load data and 90.9% for other outcomes. Virological nonsuppression decreased in both arms, but there was no evidence of an intervention effect (prevalence of nonsuppression 14.7% in the Zvandiri-PST arm versus 11.9% in the Zvandiri arm; AOR = 1.29; 95% CI 0.68, 2.48; p = 0.44). There was strong evidence of an apparent effect on common mental health outcomes (SSQ ≥8: 2.4% versus 10.3% [AOR = 0.19; 95% CI 0.08, 0.46; p < 0.001]; PHQ-9 ≥10: 2.9% versus 8.8% [AOR = 0.32; 95% CI 0.14, 0.78; p = 0.01]). Prevalence of EQ-5D index score <1 was 27.6% versus 38.9% (AOR = 0.56; 95% CI 0.31, 1.03; p = 0.06). Qualitative analyses found that CATS-observed participants had limited autonomy or ability to solve problems. In response, the CATS adapted the intervention to focus on empathic problem discussion to fit adolescents’ age, capacity, and circumstances, which was beneficial. Limitations include that cost data were not available and that the mental health tools were validated in adult populations, not adolescents.ConclusionsPST training for CATS did not add to the benefit of peer support in reducing virological nonsuppression but led to improved symptoms of CMD and depression compared to standard Zvandiri care among adolescents living with HIV in Zimbabwe. Active involvement of caregivers and strengthened referral structures could increase feasibility and effectiveness.Trial registrationPan African Clinical Trials Registry PACTR201810756862405.

Victoria Simms and co-workers report on a trial of problem discussion therapy for adolescents with HIV infection and common mental disorders in Zimbabwe.     

Depression and HIV in Botswana: a population-based study on gender-specific socioeconomic and behavioral correlates

Background

Depression is a leading contributor to the burden of disease worldwide, a critical barrier to HIV prevention and a common serious HIV co-morbidity. However, depression screening and treatment are limited in sub-Saharan Africa, and there are few population-level studies examining the prevalence and gender-specific factors associated with depression.

Methods

We conducted a cross-sectional population-based study of 18–49 year-old adults from five districts in Botswana with the highest prevalence of HIV-infection. We examined the prevalence of depressive symptoms, using a Hopkins Symptom Checklist for Depression (HSCL-D) score of ≥1.75 to define depression, and correlates of depression using multivariate logistic regression stratified by sex.

Results

Of 1,268 participants surveyed, 25.3% of women and 31.4% of men had depression. Among women, lower education (adjusted odds ratio [AOR] 2.07, 95% confidence interval [1.30–3.32]), higher income (1.77 [1.09–2.86]), and lack of control in sexual decision-making (2.35 [1.46–3.81]) were positively associated with depression. Among men, being single (1.95 [1.02–3.74]), living in a rural area (1.63 [1.02–2.65]), having frequent visits to a health provider (3.29 [1.88–5.74]), anticipated HIV stigma (fearing discrimination if HIV status was revealed) (2.04 [1.27–3.29]), and intergenerational sex (2.28 [1.17–4.41]) were independently associated with depression.

Discussion

Depression is highly prevalent in Botswana, and its correlates are gender-specific. Our findings suggest multiple targets for screening and prevention of depression and highlight the need to integrate mental health counseling and treatment into primary health care to decrease morbidity and improve HIV management efforts.     

Financial incentives and deposit contracts to promote HIV retesting in Uganda: A randomized trial

BackgroundFrequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV.Methods and findingsIn peri-urban Ugandan communities from October to December 2018, we randomized HIV–negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior.ConclusionsOffering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs.Trial registrationclinicaltrials.gov: {"type":"clinical-trial","attrs":{"text":"NCT02890459","term_id":"NCT02890459"}}NCT02890459.

Gabriel Chamie and colleagues report on a trial of financial incentives for testing in people at risk of HIV infection.     

Chronotype and depressive symptoms in students: An investigation of possible mechanisms

ABSTRACT

Individuals with an evening chronotype are at increased risk of experiencing emotional problems, including depressive symptoms. However, the mechanisms underlying these associations remain unclear. The present study aimed to determine whether poor sleep quality, substance use and cognitive emotion regulation difficulties – which have been implicated in the etiology of depression – mediate the relationship between chronotype and depressive symptoms in a student sample, which was assessed cross-sectionally and after 1 year. A total of 742 Dutch students (75% women, mean age 21.4 ± 2.9 years) completed the Quick Inventory of Depressive Symptomatology, the Morningness-Eveningness Questionnaire, the Pittsburgh Sleep Quality Index, a questionnaire assessing alcohol, caffeine, tobacco and cannabis use, the Cognitive Emotion Regulation Questionnaire and the Behavioral Inhibition/Activation Scale. A subsample (n = 115) was assessed 1 year later with the same questionnaires. Cross-sectional analyses showed that evening chronotype was associated with more depressive symptoms, adjusted for age and gender (β = ?0.082, p = 0.028). The relationship between eveningness and depressive symptoms was mediated by sleep quality, alcohol consumption and the cognitive emotion regulation strategies of self-blame and positive reappraisal. In longitudinal analyses, eveningness at baseline predicted more depressive symptoms at follow-up, adjusted for age and gender (β = ?0.29, p = 0.002); after additional adjustment for baseline depressive symptoms, chronotype remained a significant predictor of depressive symptoms at T2 (β = ?0.16, t = ?2.01, p = 0.047). Only poor sleep quality at follow-up was a significant mediator of this relationship. Even though the effect is small in terms of explained variance, eveningness is related to depressive symptoms and this relationship is mediated by poor sleep quality, also in a prospective design. Self-blame and reduced positive reappraisal are correlated with eveningness. Further research is needed to assess the efficacy of chronotherapeutic interventions for the prevention of depression, in addition to sleep education and cognitive approaches.     

High Prevalence of Severe Food Insecurity and Malnutrition among HIV-Infected Adults in Senegal,West Africa

Background

Malnutrition and food insecurity are associated with increased mortality and poor clinical outcomes among people living with HIV/AIDS; however, the prevalence of malnutrition and food insecurity among people living with HIV/AIDS in Senegal, West Africa is unknown. The objective of this study was to determine the prevalence and severity of food insecurity and malnutrition among HIV-infected adults in Senegal, and to identify associations between food insecurity, malnutrition, and HIV outcomes.

Methods

We conducted a cross-sectional study at outpatient clinics in Dakar and Ziguinchor, Senegal. Data were collected using participant interviews, anthropometry, the Household Food Insecurity Access Scale, the Individual Dietary Diversity Scale, and chart review.

Results

One hundred and nine HIV-1 and/or HIV-2 participants were enrolled. The prevalence of food insecurity was 84.6% in Dakar and 89.5% in Ziguinchor. The prevalence of severe food insecurity was 59.6% in Dakar and 75.4% in Ziguinchor. The prevalence of malnutrition (BMI <18.5) was 19.2% in Dakar and 26.3% in Ziguinchor. Severe food insecurity was associated with missing clinic appointments (p = 0.01) and not taking antiretroviral therapy due to hunger (p = 0.02). Malnutrition was associated with lower CD4 cell counts (p = 0.01).

Conclusions

Severe food insecurity and malnutrition are highly prevalent among HIV-infected adults in both Dakar and Ziguinchor, and are associated with poor HIV outcomes. Our findings warrant further studies to determine the root causes of malnutrition and food insecurity in Senegal, and the short- and long-term impacts of malnutrition and food insecurity on HIV care. Urgent interventions are needed to address the unacceptably high rates of malnutrition and food insecurity in this population.