Social and Behavioral Predictors of Adherence to Oral Antiretroviral Pre-Exposure Prophylaxis for HIV Prevention among Adolescent Girls and Young Women in Southern Africa

Adolescent girls and young women (AGYW) in sub-Saharan Africa represent a key population at risk for acquiring HIV infection. Oral antiretroviral pre-exposure prophylaxis, or PrEP, is an efficacious biomedical HIV prevention strategy that holds enormous potential to reduce HIV acquisition in key populations if taken consistently. Research is needed to identify barriers and facilitators to PrEP adherence among AGYW to inform implementation efforts. The aims of this dissertation were to examine how disclosure of PrEP use and intimate partner violence (IPV) affect adherence to daily oral PrEP among AGYW in southern Africa. We used data from two prospective cohort studies evaluating PrEP uptake and adherence among sexually-active HIV-uninfected women aged 16-25 years. Participants who initiated once daily oral PrEP were included in analyses. We first conducted descriptive analysis of PrEP use disclosure and IPV exposure variables. Participants self-reported disclosure of their PrEP use during follow-up separately for parents, partners, and peers. IPV included any self-reported physical, emotional, sexual, or psychological partner violence. Then, for both aims, we estimated the relative prevalence of high PrEP adherence at months 3 and 6, defined as TFV-DP ≥700 fmol/punch at a given visit, using univariate and multivariable (adjusted) modified Poisson or log-binomial regression. Effects were estimated in the full study population and within younger and older AGYW age group strata (dichotomized at the sample median). We did not observe a strong effect of disclosure or IPV on adherence overall; however, the effect of disclosure to a parent and IPV were significantly modified by age (α=.15). For the parent disclosure-adherence relationship, there was evidence of effect modification by age at month 6 (p=.062): among younger AGYW (≤18 years), those who disclosed to a parent were 6.8 times as likely to have high adherence at month 6 than those who did not (95% CI 1.02, 45.56); among older AGYW (>18 years), there was no significant effect of disclosure to a parent (aPR=0.69, 95% CI 0.17, 2.90). For the IPV-adherence relationship, there was evidence of effect modification by age at month 3 (p<.001): among younger AGYW (<21 years), those who reported IPV were less than half as likely to have high PrEP adherence (aPR=0.43, 95% CI 0.22, 0.86); among older AGYW (≥21 years), those who reported IPV were more than twice as likely to have high PrEP adherence (aPR=2.21, 95% CI 1.34, 3.66). There was also evidence of effect modification by age for the IPV-adherence relationship at month 6 (p=.128), and effect estimates within each age stratum were consistent in direction with month-3 results.Findings from our investigation of disclosure and PrEP adherence suggest that parents may play an important role in facilitating PrEP use among younger AGYW, and more work is needed to develop strategies for engaging parents in their child’s PrEP use. Further, adherence support programs for AGYW should find ways that peers and partners can help motivate effective PrEP use. Findings from our investigation of IPV and PrEP adherence suggest that adherence programs may be especially necessary to support younger AGYW who have experienced violence from a partner previously or are currently in a violent partnership. Further, insight into the indirect effects of IPV among older AGYW may inform efforts aimed at optimizing adherence among younger AGYW. Alternative PrEP formulations may provide benefits for AGYW who have trouble adhering to a daily oral PrEP regimen. Lastly, findings from both aims suggest that the impact of social and behavioral factors on PrEP adherence is likely to vary between younger and older AGYW. Future research should consider the transitional nature of the adolescent developmental stage when designing interventions for this group.Doctor of Philosoph

Pre-exposure prophylaxis as an opportunity for engagement in HIV prevention among South African adolescents

Pre-exposure prophylaxis (PrEP) offers a potential biomedical strategy to reduce HIV incidence among adolescent populations disproportionately affected by HIV. There is limited evidence on the social and clinical implications, including engagement in HIV prevention efforts, of PrEP for South African adolescents, who face high HIV risk. We conducted a mixed-methods study in Western Cape, South Africa from 2015 to 2016. Adolescents (N = 35) aged 16–17 and clinical service providers working with adolescents (N = 25) were recruited from community and clinic settings. Adolescents and service providers completed a survey about their overall perceptions of PrEP and completed interviews guided by semi-structured protocols. We performed descriptive analysis of quantitative data using SPSS and thematic analysis of qualitative data using NVivo. The majority of adolescents endorsed future PrEP use for themselves and partners, and all clinical service providers endorsed future PrEP use for sexually active adolescents. Both adolescents and service providers identified PrEP as an opportunity to engage youth as active participants in HIV prevention. Service providers also viewed PrEP as a potential mechanism for shifting life trajectories. Findings from this study enhance our understanding of the considerations needed to engage adolescents and clinical service providers in the roll-out of oral PrEP in South Africa

Khuluma : using participatory, peer-led and digital methods to deliver psychosocial support to young people living with HIV in South Africa

Khuluma is a psychosocial and peer-to-peer mHealth intervention that uses text messaging to facilitate support groups for adolescents living with HIV (ALWH) with the aim of contributing toward positive health outcomes. Although use of mobile technology in the form of mHealth interventions has proliferated recently in the field of health, published literature describing methods and processes of its application are limited. We present a set of methods and processes utilised to develop and pilot the Khuluma mHealth intervention amongst young people (15–20 years) in South Africa. We recruited and enrolled 52 adolescents (15–20-year olds) from four clinics in Pretoria and Cape Town to participate in a 6-month pilot of Khuluma. Participants were ALWH, aware of their status, on antiretroviral therapy for more than 12 months, and not suffering from severe depression. We conducted four pre and post intervention focus group discussions (FGDs) with a proportion of ALWH (n = 36) enrolled in the pilot study using participatory methods. Several processes were utilised to then implement this pilot study. These included engaging ALWH for minor study implementation modifications; forming virtual groups; activating the mHealth platform; facilitating and delivering the Khuluma intervention. The acceptability of the intervention was informed by follow-up focus group discussions and text message data. The initial participatory processes helped to tailor the intervention design to participants’ needs. The peer-led facilitation of the groups allowed for the provision of sensitive psychosocial support that allowed young people to express themselves freely, develop a sense of self-worth, and interact more. The nature of themobile technology also allowed participants to build friendships beyond their geographic area and interact with their peers in real time. Within the evolving context of COVID-19, establishing evidence-based processes and methods for intervention design and curation in virtual spaces is critical.SHM Foundation. Text messages were donated by Vodacom SA.https://www.frontiersin.org/journals/reproductive-health#am2022Psycholog

Assessing risk for HIV infection among adolescent girls in South Africa: an evaluation of the VOICE risk score (HPTN 068)

INTRODUCTION: To maximize impact and minimize costs, antiretroviral pre-exposure prophylaxis (PrEP) interventions should be offered to those at highest risk for HIV infection. The risk score derived from the VOICE trial is one tool currently being utilized to determine eligibility in adolescent PrEP trials in sub-Saharan Africa. This study is aimed at evaluating the utility of the risk score in predicting HIV incidence among a cohort of adolescent girls in rural South Africa. METHODS: We utilized data from HIV Prevention Trials Network (HPTN) 068, a phase III randomized controlled trial conducted in rural Mpumalanga province, South Africa. School-attending young women aged 13 to 20 years were enrolled into the trial from 2011 to 2012 and followed for up to three years. A risk score based on individual-level risk factors measured at enrolment was calculated for HPTN 068 participants who completed a one-year follow-up visit and were HIV seronegative at enrolment. Possible scores ranged from 0 to 10. A proportional hazards model was then used to determine if risk score at enrolment was predictive of incident HIV infection at follow-up and an area under the curve analysis was used to examine the predictive ability of the score. RESULTS AND DISCUSSION: The risk score had limited variability in the HPTN 068 sample. Scores ≥5 identified 85% of incident infections from 94% of the sample, compared to the VOICE sample in which scores ≥5 identified 91% of incident infections from only 64% of participants. The risk score did not predict HIV incidence after one year of follow-up (hazard ratio = 1.029; 95% confidence interval (CI): 0.704, 1.503, p = .884) and showed poor predictive ability (area under the curve = 0.55; 95% CI: 0.44, 0.65). Certain individual risk factors that comprise the risk score may be context specific or not relevant for adolescent populations. Additional factors should be considered when assessing risk for the purposes of determining PrEP eligibility. CONCLUSIONS: The VOICE risk score demonstrated low utility to predict HIV incidence in the HPTN 068 sample. Findings highlight the need for an age and developmentally appropriate tool for assessing risk for HIV infection among adolescents. Use of the VOICE risk score for determining PrEP eligibility in younger populations should be carefully considered

Social isolation and psychological distress among southern U.S. college students in the era of COVID-19

Background College students are at heightened risk for negative psychological outcomes due to COVID-19. We examined the prevalence of psychological distress and its association with social isolation among public university students in the southern United States. Methods A cross-sectional survey was emailed to all University of North Carolina-Chapel Hill students in June 2020 and was open for two weeks. Students self-reported if they were self-isolating none, some, most, or all of the time. Validated screening instruments were used to assess clinically significant symptoms of depression, loneliness, and increased perceived stress. The data was weighted to the complete student population. Results 7,012 completed surveys were included. Almost two-thirds (64%) of the students reported clinically significant depressive symptoms and 65% were categorized as lonely. An estimated 64% of students reported self-isolating most or all of the time. Compared to those self-isolating none of the time, students self-isolating some of the time were 1.78 (95% CI 1.37, 2.30) times as likely to report clinically significant depressive symptoms, and students self-isolating most or all of the time were 2.12 (95% CI 1.64, 2.74) and 2.27 (95% CI 1.75, 2.94) times as likely to report clinically significant depressive symptoms, respectively. Similar associations between self-isolation and loneliness and perceived stress were observed. Conclusions The prevalence of adverse mental health indicators among this sample of university students in June 2020 was exceptionally high. University responses to the COVID-19 pandemic should prioritize student mental health and prepare a range of support services to mitigate mental health consequences as the pandemic continues to evolve

Associations between psychosocial wellbeing and experience of gender-based violence at community, household, and intimate-partner levels among a cross-sectional cohort of young people living with and without HIV during COVID-19 in Cape Town, South Africa

Background Growing evidence indicates that gender-based violence (GBV) increased during COVID-19. We investigated self-reported impact of the pandemic on GBV at community, household and intimate partner (IPV) levels among young people and its associations with psychosocial wellbeing, i.e., COVID-related stressors and mental health. Methods Cross-sectional data were drawn from a survey with young people ages 13–24 (N = 536) living with HIV (YPLWH) and without HIV (YPLWoH), in peri-urban Cape Town, South Africa. The survey, conducted February-October 2021, examined the impact of the initial lockdown on experience and perceived changes in GBV at each level, and pandemic-related psychosocial wellbeing. Descriptive statistics and binomial and multinomial regression analyses were conducted to illustrate exposure and perceived changes in GBV since lockdown, and their association with COVID-related stress factors (e.g., social isolation, anxiety about COVID), mental health (e.g., depression, anxiety), and other risk factors (e.g., age, gender, socioeconomic status) by HIV status. Results Participants were 70% women with mean age 19 years; 40% were living with HIV. Since lockdown, YPLWoH were significantly more likely than YPLWH to perceive community violence as increasing (45% vs. 28%, p < 0.001), and to report household violence (37% vs. 23%, p = 0.006) and perceive it as increasing (56% vs. 27%, p = 0.002) (ref: decreasing violence). YPLWoH were also more likely to report IPV experience (19% vs. 15%, p = 0.41) and perception of IPV increasing (15% vs. 8%, p = 0.92). In adjusted models, COVID-related stressors and common mental health disorders were only associated with household violence. However, indicators of economic status such as living in informal housing (RRR = 2.07; 95% CI = 1.12–3.83) and food insecurity (Community violence: RRR = 1.79; 95% CI = 1.00-3.20; Household violence: RRR = 1.72; 95% CI = 1.15–2.60) emerged as significant risk factors for exposure to increased GBV particularly among YPLWoH. Conclusions Findings suggest that for young people in this setting, GBV at community and household levels was more prevalent during COVID-19 compared to IPV, especially for YPLWoH. While we found limited associations between COVID-related stressors and GBV, the perceived increases in GBV since lockdown in a setting where GBV is endemic, and the association of household violence with mental health, is a concern for future pandemic responses and should be longitudinally assessed. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-023-16945-5

Oral pre-exposure prophylaxis uptake, adherence, and adverse events among South African men who have sex with men and transgender women

DATA AVAILABILITY : Data that support the findings may contain identifying or sensitive patient information. To preserve participant confidentiality, these data cannot be shared publicly. The principal investigator of this study, P.S.S. (pssulli@emory. edu), can be contacted with requests to access these data.BACKGROUND : HIV prevention programmes that include pre-exposure prophylaxis (PrEP) for men who have sex with men (MSM) and transgender women (TGW) in South Africa have not been widely implemented. OBJECTIVES : The authors examined oral PrEP uptake, adherence, and adverse events among HIV-uninfected MSM and TGW to inform intervention acceptability and feasibility. METHOD : In 2015, MSM and TGW in two South African cities were offered a comprehensive package of HIV prevention services, including daily oral PrEP, and were followed for one year. Different models of PrEP delivery were used at each site. Adherence was measured using self-report and pill-count data and tenofovir-diphosphate (TFV-DP) concentrations. RESULTS : Among 135 participants who were eligible for PrEP, 82 (61%) initiated PrEP, of whom 67 (82%) were on PrEP at study end. Participants were on PrEP for a median of 294 out of 314.5 possible days (93% protected days). The median time from PrEP initiation to discontinuation or study end was 305 days (interquartile range: 232–325 days). Across the follow-up time points, 57% – 72% of participants self-reported taking protective levels of PrEP and 59% – 74% were adherent to PrEP as indicated by pill counts. Fewer (≤ 18%) achieved protective TFV-DP concentrations of ≥ 700 fmol/punch in dried blood spots. Side effects, while typically mild, were the most commonly cited reason by participants for early PrEP discontinuation. CONCLUSION : Many MSM and TGW initiated and maintained PrEP, demonstrating that PrEP can be successfully delivered to South African MSM and TGW in diverse programmatic contexts. Biologic adherence measures suggest MSM and TGW may experience challenges taking PrEP regularly. Counselling for coping with side effects and motivating daily pill taking is recommended to support South African MSM and TGW in achieving protection with PrEP.The Center for AIDS Research at Emory University and the National Institute for Allergy and Infectious Diseases.http://www.sajhivmed.org.zaam2023School of Health Systems and Public Health (SHSPH

Socioeconomic inequalities in the 90–90–90 target, among people living with HIV in 12 sub-Saharan African countries — Implications for achieving the 95–95–95 target — Analysis of population-based surveys

Background Inequalities undermine efforts to end AIDS by 2030. We examined socioeconomic inequalities in the 90–90–90 target among people living with HIV (PLHIV) —men (MLHIV), women (WLHIV) and adolescents (ALHIV). Methods We analysed the available Population HIV Impact Assessment (PHIA) survey data for each of the 12 sub-Saharan African countries, collected between 2015 and 2018 to estimate the attainment of each step of the 90–90–90 target by wealth quintiles. We constructed concentration curves, computed concentration indices (CIX) —a negative (positive) CIX indicated pro-poor (pro-rich) inequalities— and identified factors associated with, and contributing to inequality. Findings Socioeconomic inequalities in achieving the 90–90–90 target components among PLHIV were noted in 11 of the 12 countries surveyed: not in Rwanda. Awareness of HIV positive status was pro-rich in 5/12 countries (Côte d'Ivoire, Tanzania, Uganda, Malawi, and Zambia) ranging from CIX=0·085 (p&lt; 0·05) in Tanzania for PLHIV, to CIX = 0·378 (p&lt;0·1) in Côte d'Ivoire for ALHIV. It was pro-poor in 5/12 countries (Côte d'Ivoire, Ethiopia, Malawi, Namibia and Eswatini), ranging from CIX = -0·076 (p&lt;0·05) for PLHIV in Eswatini, and CIX = -0·192 (p&lt;0·05) for WLHIV in Ethiopia. Inequalities in accessing ART were pro-rich in 5/12 countries (Cameroun, Tanzania, Uganda, Malawi and Zambia) ranging from CIX=0·101 (p&lt;0·05) among PLHIV in Zambia to CIX=0·774 (p&lt;0·1) among ALHIV in Cameroun and pro-poor in 4/12 countries (Tanzania, Zimbabwe, Lesotho and Eswatini), ranging from CIX = -0·072 (p&lt;0·1) among PLHIV in Zimbabwe to CIX = -0·203 (p&lt;0·05) among WLHIV in Tanzania. Inequalities in HIV viral load suppression were pro-rich in 3/12 countries (Ethiopia, Uganda, and Lesotho), ranging from CIX = 0·089 (p&lt; 0·1) among PLHIV in Uganda to CIX = 0·275 (p&lt;0·01) among WLHIV in Ethiopia. Three countries (Tanzania CIX = 0·069 (p&lt; 0·5), Uganda CIX = 0·077 (p&lt; 0·1), and Zambia CIX = 0·116 (p&lt; 0·1)) reported pro-rich and three countries (Côte d'Ivoire CIX = -0·125 (p&lt; 0·1), Namibia CIX = -0·076 (p&lt; 0·05), and Eswatini CIX = -0·050 (p&lt; 0·05) reported pro-poor inequalities for the cumulative CIX for HIV viral load suppression. The decomposition analysis showed that age, rural-urban residence, education, and wealth were associated with and contributed the most to inequalities observed in achieving the 90–90–90 target. Interpretation Some PLHIV in 11 of 12 countries were not receiving life-saving HIV testing, treatment, or achieving HIV viral load suppression due to socioeconomic inequalities. Socioeconomic factors were associated with and explained the inequalities observed in the 90–90–90 target among PLHIV. Governments should scale up equitable 95–95–95 target interventions, prioritizing the reduction of age, rural-urban, education and wealth-related inequalities. Research is needed to understand interventions to reduce socioeconomic inequities in achieving the 95–95–95 target

Social isolation and psychological distress among southern U.S. college students in the era of COVID-19.

BackgroundCollege students are at heightened risk for negative psychological outcomes due to COVID-19. We examined the prevalence of psychological distress and its association with social isolation among public university students in the southern United States.MethodsA cross-sectional survey was emailed to all University of North Carolina-Chapel Hill students in June 2020 and was open for two weeks. Students self-reported if they were self-isolating none, some, most, or all of the time. Validated screening instruments were used to assess clinically significant symptoms of depression, loneliness, and increased perceived stress. The data was weighted to the complete student population.Results7,012 completed surveys were included. Almost two-thirds (64%) of the students reported clinically significant depressive symptoms and 65% were categorized as lonely. An estimated 64% of students reported self-isolating most or all of the time. Compared to those self-isolating none of the time, students self-isolating some of the time were 1.78 (95% CI 1.37, 2.30) times as likely to report clinically significant depressive symptoms, and students self-isolating most or all of the time were 2.12 (95% CI 1.64, 2.74) and 2.27 (95% CI 1.75, 2.94) times as likely to report clinically significant depressive symptoms, respectively. Similar associations between self-isolation and loneliness and perceived stress were observed.ConclusionsThe prevalence of adverse mental health indicators among this sample of university students in June 2020 was exceptionally high. University responses to the COVID-19 pandemic should prioritize student mental health and prepare a range of support services to mitigate mental health consequences as the pandemic continues to evolve

Self-Esteem as an Indicator of Transactional Sex Among Young Women in Rural South Africa (HPTN 068)

2019, Springer Science+Business Media, LLC, part of Springer Nature. Transactional sex (TS) has been shown to contribute to the HIV epidemic in sub-Saharan Africa. Previous research has yet to identify psychosocial factors that make young women vulnerable to engaging in TS. This analysis examined the association between self-esteem and TS among young women in rural South Africa. A post hoc analysis of post-intervention survey data from HPTN 068 was conducted. Log-binomial regression was used to compute a prevalence ratio measure of association. Among 1942 young women, the prevalence of TS among those with lower self-esteem was 4.7 times the prevalence of TS among those with higher self-esteem (p \u3c 0.001). Findings provide support for the association between lower self-esteem and TS in this context and may inform intervention development