Association between attachment and mental health symptoms among school-going adolescents in Northern Uganda: the moderating role of war-related trauma

Background: The association between attachment and mental health symptoms in adolescents in a post-conflict low resource setting has not been documented. Methods: We investigated the relationship between parent and peer attachment and posttraumatic stress, depression and anxiety symptoms in a sample of 551 adolescents aged 13-21 years old. Attachment quality was assessed using the Inventory of Parent and Peer Attachment (IPPA). Post-traumatic stress, depression and anxiety symptoms were assessed using the Impact of Events Scale Revised (IESR) and Hopkins Symptom Checklist for Adolescents (HSCL-37A) respectively. Gender differences in attachment relationships were determined using independent t-tests. Multivariate logistic regression was used to assess whether attachment relationships were independently associated with posttraumatic stress, depression and anxiety symptoms. Hierarchical linear regression analyses were conducted to explore the moderating role of war-related trauma. Results: Our analyses revealed gender differences in attachment to parents, with males reporting stronger attachment than females. Parental attachment was protective against depression and anxiety symptoms but not posttraumatic stress symptoms after adjusting for potential confounders. Alienation by parents was independently associated with an increase in these mental health symptoms while peer attachment was not associated with any of these symptoms. However, in situations of severe trauma, our analyses showed that peer attachment was significantly protective against post-traumatic stress symptoms. Conclusions: Secure parental attachment is associated with better psychosocial adjustment in adolescents affected by war. Further, adolescents with secure peer attachment relationships in situations of severe war trauma may be less likely to develop posttraumatic stress symptoms. Interventions to enhance peer support in this post conflict setting would benefit this vulnerable population

Effect of HIV infection on time to recovery from an acute manic episode

E Nakimuli-Mpungu1,2,3, B Mutamba2,3, S Nshemerirwe2,3, MS Kiwuwa4, S Musisi21Mental Health Department, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; 2Department of Psychiatry, Makerere College of Health Sciences, School of Medicine, Kampala; 3Butabika National Referral Mental Hospital, Ministry of Health, Kampala; 4Clinical Epidemiology Unit, Makerere College of Health Sciences, School of Medicine, Kampala, UgandaIntroduction: Understanding factors affecting the time to recovery from acute mania is critical in the management of manic syndromes. The aim of this study was to determine the effect of HIV infection on time to recovery from acute mania.Methods: We performed a retrospective study in which medical charts of individuals who were treated for acute mania were reviewed. Survival analysis with Cox regression models were used to compare time to recovery from an acute manic episode between human immunodeficiency virus (HIV)-positive individuals and HIV-negative individuals.Results: Median survival time was one week for HIV-positive individuals and more than four weeks for HIV-negative individuals (Χ2 = 18.4, P value = 0.000). HIV infection was the only marginally significant independent predictor of survival probability on the acute admission ward (hazards ratio 2.87, P = 0.06).Conclusion: Acute mania in HIV-infected persons responds faster to psychotropic drugs compared with that in HIV-negative persons.Keywords: HIV-related mania, bipolar disorder, HIV infection, Uganda, immunodeficiency viru

How COVID-19 has fundamentally changed clinical research in global health

COVID-19 has had negative repercussions on the entire global population. Despite there being a common goal that should have unified resources and efforts, there have been an overwhelmingly large number of clinical trials that have been registered that are of questionable methodological quality. As the final paper of this Series, we discuss how the medical research community has responded to COVID-19. We recognise the incredible pressure that this pandemic has put on researchers, regulators, and policy makers, all of whom were doing their best to move quickly but safely in a time of tremendous uncertainty. However, the research community\u27s response to the COVID-19 pandemic has prominently highlighted many fundamental issues that exist in clinical trial research under the current system and its incentive structures. The COVID-19 pandemic has not only re-emphasised the importance of well designed randomised clinical trials but also highlighted the need for large-scale clinical trials structured according to a master protocol in a coordinated and collaborative manner. There is also a need for structures and incentives to enable faster data sharing of anonymised datasets, and a need to provide similar opportunities to those in high-income countries for clinical trial research in low-resource regions where clinical trial research receives considerably less research funding

Sub-Optimal Vitamin B-12 Levels among ART-Naïve HIV-Positive Individuals in an Urban Cohort in Uganda

Malnutrition is common among HIV-infected individuals and is often accompanied by low serum levels of micronutrients. Vitamin B-12 deficiency has been associated with various factors including faster HIV disease progression and CD4 depletion in resource-rich settings. To describe prevalence and factors associated with sub-optimal vitamin B-12 levels among HIV-infected antiretroviral therapy (ART) naïve adults in a resource-poor setting, we performed a cross-sectional study with a retrospective chart review among individuals attending either the Mulago-Mbarara teaching hospitals’ Joint AIDS Program (MJAP) or the Infectious Diseases Institute (IDI) clinics, in Kampala, Uganda. Logistic regression was used to determine factors associated with sub-optimal vitamin B-12. The mean vitamin B-12 level was 384 pg/ml, normal range (200–900). Sub-optimal vitamin B-12 levels (<300 pg/ml) were found in 75/204 (36.8%). Twenty-one of 204 (10.3%) had vitamin B-12 deficiency (<200 pg/ml) while 54/204 (26.5%) had marginal depletion (200–300 pg/ml). Irritable mood was observed more among individuals with sub-optimal vitamin B-12 levels (OR 2.5, 95% CI; 1.1–5.6, P = 0.03). Increasing MCV was associated with decreasing serum B-12 category; 86.9 fl (±5.1) vs. 83 fl (±8.4) vs. 82 fl (±8.4) for B-12 deficiency, marginal and normal B-12 categories respectively (test for trend, P = 0.017). Compared to normal B-12, individuals with vitamin B-12 deficiency had a longer known duration of HIV infection: 42.2 months (±27.1) vs. 29.4 months (±23.8; P = 0.02). Participants eligible for ART (CD4<350 cells/µl) with sub-optimal B-12 had a higher mean rate of CD4 decline compared to counterparts with normal B-12; 118 (±145) vs. 22 (±115) cells/µl/year, P = 0.01 respectively. The prevalence of a sub-optimal vitamin B-12 was high in this HIV-infected, ART-naïve adult clinic population in urban Uganda. We recommend prospective studies to further clarify the causal relationships of sub-optimal vitamin B-12, and explore the role of vitamin B-12 supplementation in immune recovery

Author's Response: Targeting Treatments to Health Disparities

These initial data suggest that with prenatal vitamins and choline supplements, we might decrease one risk factor associated with poorer health outcomes disproportionally affecting Black families, ie, preterm birth. Dissemination of this research fulfills the principle of Justice in the Belmont Report, to ensure that participants from different racial, ethnic and socioeconomic groups receive benefits from research directed to their specific problems

Black American Maternal Prenatal Choline, Offspring Gestational Age at Birth, and Developmental Predisposition to Mental Illness

Black Americans have increased risk for schizophrenia and other mental illnesses with prenatal origins. Prenatal choline promotes infant brain development and behavioral outcomes, but choline has not been specifically assessed in Black Americans. Pregnant women (N = 183, N = 25 Black Americans) enrolled in a study of prenatal stressors and interactions with prenatal choline. Black American women had lower 16-week gestation plasma choline than Whites. Lower choline was not related to obesity, income, or metabolic genotypes. Pregnant women in rural Uganda have higher choline levels than Black American women. Black Americans' lower choline was associated with higher hair cortisol, indicative of higher stress. Lower maternal choline was associated with offsprings' lower gestational age at birth and with decreased auditory P50 inhibition, a marker of inhibitory neuron development. Behavioral development was assessed on the Infant Behavior Questionnaire-R-SF (IBQ-R) at 3 months. Lower Black American maternal gestational choline was associated with lower infant IBQ-R Orienting/Regulation, indicating decreased attention and relation to caregivers. Additional evidence for developmental effects of choline in Black Americans comes from a randomized clinical trial of gestational phosphatidylcholine supplementation versus placebo that included 15 Black Americans. Phosphatidylcholine increased gestational age at birth and newborn P50 inhibition and decreased Social Withdrawn and Attention problems at 40 months of age in Black Americans' offspring compared to placebo. Inhibitory and behavioral deficits associated with lower prenatal choline in offspring of Black American women indicate potential developmental predispositions to later mental illnesses that might be ameliorated by prenatal choline or phosphatidylcholine supplementation

Prevalence and risk factors of major depressive disorder in HIV/AIDS as seen in semi-urban Entebbe district, Uganda

BACKGROUND: Not much is known about the risk factors of major depressive disorder (MDD) in HIV/AIDS in the African socio-cultural context. Therefore a study was undertaken to examine the prevalence and risk factors of MDD in HIV/AIDS in semi-urban Uganda. METHODS: A cross-sectional study was undertaken among 618 respondents attending two HIV clinics in Uganda. RESULTS: Prevalence of MDD was 8.1%. Factors associated with MDD at univariate analysis only were female gender, family history of mental illness, negative coping style, alcohol dependency disorder, food insecurity and stress; not associated with MDD were social support, neurocognitive impairment, CD4 counts and BMI. Factors independently associated with MDD were psychosocial impairment, adverse life events, post traumatic stress disorder, generalised anxiety disorder and life-time attempted suicide. CONCLUSION: Psychological and social factors were the main risk factors of MDD among ambulatory HIV positive persons with no evidence for the role of the neurotoxic effects of HIV. Treatment approaches for MDD in this patient group should be modeled on those used among non-HIV groups

The association between aids related stigma and major depressive disorder among HIV-positive individuals in Uganda

BACKGROUND: Major depressive disorder in people living with HIV/AIDS (PLWHA) is common and may be associated with a number of factors, including AIDS-related stigma, decreased CD4 levels, increased opportunistic infections and sociodemographic variables. The extent to which AIDS-related stigma is associated with major depressive disorder among PLWHA has not been well studied in sub-Saharan Africa. The objective of this study was to examine the associations between major depressive disorder, AIDS-related stigma, immune status, and sociodemographic variables with the aim of making recommendations that can guide clinicians. METHODS: We assessed 368 PLWHA for major depressive disorder, as well as for potentially associated factors, including AIDS-related stigma, CD4 levels, presence of opportunistic infections, and sociodemographic variables. RESULTS: The prevalence of major depressive disorder was 17.4%, while 7.9% of the participants had AIDS related stigma. At multivariable analysis, major depressive disorder was significantly associated with AIDS-related stigma [OR = 1.65, CI (1.20-2.26)], a CD4 count of ≥200 [OR 0.52 CI (0.27-0.99)], and being of younger age [0.95, CI (0.92-0.98). CONCLUSIONS: Due to the high burden of major depressive disorder, and its association with AIDS related stigma, routine screening of PLWHA for both conditions is recommended. However, more research is required to understand this association

Behavioral and cognitive interventions to improve treatment adherence and access to HIV care among older adults in sub-Saharan Africa: an updated systematic review

BACKGROUND: Approximately 14% of Africans infected with HIV are over the age of 50, yet few intervention studies focus on improving access to care, retention in care, and adherence to antiretroviral therapy (ART) in this population. A review of the published literature until 2012, found no relevant ART management and care interventions for older people living with HIV (OPLHIV) in sub-Saharan Africa. The aim of this systematic review is to update the original systematic review of intervention studies on OPLHIV, with a focus on evidence from sub-Saharan Africa. METHODS: We conducted a systematic review of the available published literature from 2012 to 2017 to explore behavioral and cognitive interventions addressing access to ART, retention in HIV care and adherence to ART in sub-Saharan Africa that include older adults (50+). We searched three databases (MEDLINE, EMBASE, and Education Resources Information Center) using relevant Medical Subject Headings (MeSH) terms as well as a manual search of the reference lists. No language restrictions were placed. We identified eight articles which were analyzed using content analysis with additional information obtained directly from the corresponding authors. RESULTS AND DISCUSSION: There were no studies that exclusively focused on OPLHIV. Three studies referred only to participants being over 18 years and did not specify age categories. Therefore, it is unclear whether these studies actively considered people living with HIV over the age of 50. Although the studies sampled older adults, they lacked sufficient data to draw conclusions about the relevance of the outcomes of this group. CONCLUSIONS: These findings underscore the need to increase the evidence-base of which interventions will work for older Africans on ART