Perceived need, barriers to and facilitators of mental health care among HIV-infected PWID in Hanoi, Vietnam: A qualitative study

Background: The HIV epidemic in Vietnam has been primarily driven by injection drug use. HIV-infected people who inject drugs (PWID) in Vietnam have very high rates of mental health problems, which can accelerate progression to AIDS and increase mortality rates. No research has explored the barriers and facilitators of mental health care for HIV-infected PWID in Vietnam. Methods: We conducted 28 in-depth interviews among HIV-infected PWID (n = 16), HIV and MMT (methadone maintenance treatment) providers (n = 8), and health officials (n = 4) in Hanoi. We explored participants' perceptions of mental health disorders, and barriers and facilitators to seeking and receiving mental health care. Results: HIV-infected PWID were perceived by both PWID, HIV/MMT providers, and health officials to be vulnerable to mental health problems and to have great need for mental health care. Perceived social, physical, and economical barriers included stigma towards HIV, injection drug use, and mental illnesses; lack of awareness around mental health issues; lack of human resources, facilities and information on mental health services; and limited affordability of mental health services. Social support from family and healthcare providers was a perceived facilitator of mental health care. Conclusions: Interventions should raise self-awareness of HIV-infected PWID about common mental health problems; address social, physical, economic barriers to seeking mental health services; and increase social support for patients

Depression and coping strategies among Vietnamese women living with HIV: A qualitative study

Women living with HIV (WLWH) are more likely to suffer from depression than seronegative women and are also more likely to suffer from depression than men living with HIV. There is limited depression research with WLWH in Vietnam. Twenty in-depth interviews with WLWH were conducted to identify pathways leading to depression and coping strategies for depression. Participants were recruited from an antiretroviral treatment clinic in northern Vietnam. Audio-recorded interviews were transcribed, translated, and analysed to identify key themes. All participants reported sudden loss of social support, debilitating depression, and suicidal ideation in the first six months after HIV diagnosis. While some were able to cope with their status after several months, others continued to struggle due to HIV-related stigma that was perceived as more isolating for WLWH than for men. Women who were able to effectively cope with depression found ways to re-establish connections to family and community. Interventions to improve mental wellbeing should link WLWH to mental health services immediately after diagnosis and address loss of support and stigma, as they contributed to the onset and persistence of depression after HIV diagnosis. Community-level HIV stigma reduction interventions may also help repair broken social bonds and foster new ones

The opioid and related drug epidemics in rural Appalachia: A systematic review of populations affected, risk factors, and infectious diseases

Background/aims: To examine trends in rural Appalachian opioid and related drug epidemics during the past 10 years, including at-risk populations, substance use shifts and correlates, and associated infections. Methods: We conducted this review in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Seven databases were searched for quantitative studies, published between January 2006 and December 2017, of drug use, drug-related mortality, or associated infections in rural Appalachia. Results: Drug-related deaths increased in study states, and a high incidence of polydrug toxicity was noted. Rural substance use was most common among young, white males, with low education levels. A history of depression/anxiety was common among study populations. Prescription opioids were most commonly used, often in conjunction with sedatives. Women emerged as a distinct user subpopulation, with different routes of drug use initiation and drug sources. Injection drug use was accompanied by risky injection behaviors and was associated with hepatitis C. Conclusions: This review can help to inform substance use intervention development and implementation in rural Appalachian populations. Those at highest risk are young, white males who often engage in polysubstance use and have a history of mental health issues. Differences in risk factors among other groups and characteristics of drug use in rural Appalachian populations that are conducive to human immunodeficiency virus (HIV) spread also warrant consideration

Peer norms moderate the association between mental health and sexual risk behaviors among young men living in Dar es Salaam, Tanzania

Background Young men living in Dar es Salaam's informal settlements face environmental stressors that may expose them to multiple determinants of HIV risk including poor mental health and risky sexual behavior norms. We aimed to understand how these co-occurring risk factors not only independently affect men's condom use and sexual partner concurrency, but also how they interact to shape these risk behaviors. Methods Participants in the study were male members of 59 social groups known as “camps” in Dar es Salaam, Tanzania. We assessed moderation by changes in peer norms of the association between changes in symptoms of anxiety and depression and sexual risk behaviors (condom use and sexual partner concurrency) among 1113 sexually active men. Participants nominated their three closest friends in their camp and reported their perceptions of these friends' behaviors, attitudes, and encouragement of condom use and concurrency. Anxiety and depression were measured using the HSCL-25, and condom use and sexual partner concurrency were assessed through self-report. Results Perceptions of decreasing condom use among friends (descriptive norms) and decreasing encouragement of condom use were associated with lower levels of condom use. Perceptions of increasing partner concurrency and acceptability of partner concurrency (injunctive norms) among friends were associated with higher odds of concurrency. Changes in perceived condom use norms (descriptive norms and encouragement) interacted with changes in anxiety symptoms in association with condom use such that the negative relationship was amplified by norms less favorable for condom use, and attenuated by more favorable norms for condom use. Conclusions These results provide novel evidence of the interacting effects of poor mental health and risky sexual behavior norms among a hard to reach population of marginalized young men in Dar es Salaam. Our findings provide important information for future norms-based and mental health promotion interventions targeting HIV prevention in this key population

Changes in Anxiety and Depression Symptoms Predict Sexual Risk Behaviors Among Young Men Living in Dar es Salaam, Tanzania

Young men are important targets in HIV prevention in Tanzania and throughout sub-Saharan Africa. Anxiety and depression are common among youth and may be important predictors of HIV risk behaviors; evidence of these relationships in high-risk populations is needed. Using baseline and 1 year follow-up assessments from an HIV prevention trial we assessed the association between changes in symptoms of anxiety and depression and follow-up sexual risk behaviors (condom use and sexual partner concurrency) controlling for baseline sexual risk behaviors among 1113 male members of social groups known as “camps” in Dar es Salaam, Tanzania. Anxiety and depression were measured using the HSCL-25 and condom use and sexual partner concurrency were assessed through self-report. In separate models, increases in anxiety and depression were associated with sexual partner concurrency and with lower levels of condom use. In a combined model, both anxiety and depression appeared to independently affect concurrency but only depression was independently associated with condom use, with the association between anxiety and condom use being likely attributable to covariance with depression symptoms. The results of this study indicate the importance of screening and providing treatment for depression and anxiety disorders in high HIV-prevalence contexts, and the need to develop effective HIV prevention interventions targeting young men living with anxiety and depression

The relationship between health-related variables and increases in smoking among recently diagnosed HIV+ people who inject drugs in Vietnam

Background: In Vietnam tobacco smoking is prevalent among people living with HIV (PLHIV) and causes excess mortality in this population. Injection drug use is a driver of HIV infections in Vietnam. Changes in HIV disease state may correlate to changes in smoking among PLHIV. This study investigates the relationship between increases in smoking and health-related variables among recently diagnosed HIV+ people who inject drugs (PWID) in Vietnam. Methods: We analyzed longitudinal data from 323 recently diagnosed HIV+ PWID in a randomized controlled trial from 2009 to 2013 in Thai Nguyen province, Vietnam. The outcome was an increase of >one cigarette/day from baseline visit cigarette smoking. A generalized estimating equation for repeated measures was used to estimate bivariable and multivariable associations between participant characteristics and smoking increases. We collected qualitative data to enhance our understanding of quantitative results, from 16 HIV+ PWID who smoke. Results: Ninety three point 5% of participants reported some smoking at baseline. Smoking fewer cigarettes, higher health related quality of life (QOL), and higher CD4 counts were predictive of increases in smoking at future visits in a multivariable model. Qualitative data showed smoking increases were tied to improved perceived health, and counseling during respiratory illnesses may increase intention to quit. Conclusion: HIV+ PWID in Vietnam smoke at a very high rate. Increases in their smoking are correlated to increases in heath-related QOL, and increases in perceptions of health. Any tobacco-use intervention should account for internal tobacco use triggers faced by HIV+ PWID

“I Was Raised in Addiction”: Constructions of the Self and the Other in Discourses of Addiction and Recovery

The aim of this article is to address how conceptualizations of addiction shape the lived experiences of people who use drugs (PWUDs) during the current opioid epidemic. Using a discourse analytic approach, we examine interview transcripts from 27 PWUDs in rural Appalachian Ohio. We investigate the ways in which participants talk about their substance use, what these linguistic choices reveal about their conceptions of self and other PWUDs, and how participants’ discursive caches might be constrained by or defined within broader social discourses. We highlight three subject positions enacted by participants during the interviews: addict as victim of circumstance, addict as good Samaritan, and addict as motivated for change. We argue participants leverage these positions to contrast themselves with a reified addict-other whose identity carries socially ascribed characteristics of being blameworthy, immoral, callous, and complicit. We implicate these processes in the perpetuation of intragroup stigma and discuss implications for intervention

Estimating the Effect of Depression on HIV Transmission Risk Behaviors Among People Who Inject Drugs in Vietnam: A Causal Approach

The burden of depression and HIV is high among people who inject drugs (PWID), yet the effect of depression on transmission risk behaviors is not well understood in this population. Using causal inference methods, we analyzed data from 455 PWID living with HIV in Vietnam 2009–2013. Study visits every 6 months over 2 years measured depressive symptoms in the past week and injecting and sexual behaviors in the prior 3 months. Severe depressive symptoms (vs. mild/no symptoms) increased injection equipment sharing (risk difference [RD] = 3.9 percentage points, 95% CI −1.7, 9.6) but not condomless sex (RD = −1.8, 95% CI −6.4, 2.8) as reported 6 months later. The cross-sectional association with injection equipment sharing at the same visit (RD = 6.2, 95% CI 1.4, 11.0) was stronger than the longitudinal effect. Interventions on depression among PWID may decrease sharing of injection equipment and the corresponding risk of HIV transmission. Clinical trial registration ClinicalTrials.gov NCT01689545

The role of depression in secondary HIV transmission among people who inject drugs in Vietnam: A mathematical modeling analysis

Background Among people who inject drugs (PWID), depression burden is high and may interfere with HIV prevention efforts. Although depression is known to affect injecting behaviors and HIV treatment, its overall impact on HIV transmission has not been quantified. Using mathematical modeling, we sought to estimate secondary HIV transmissions and identify differences by depression among PWID. Methods We analyzed longitudinal data from 455 PWID living with HIV in Vietnam during 2009–2013. Using a Bernoulli process model with individual-level viral load and behavioral data from baseline and 6-month follow-up visits, we estimated secondary HIV transmission events from participants to their potentially susceptible injecting partners. To evaluate differences by depression, we compared modeled transmissions per 1,000 PWID across depressive symptom categories (severe, mild, or no symptoms) in the three months before each visit. Results We estimated a median of 41.2 (2.5th, 97.5th percentiles: 33.2–49.2) secondary transmissions from all reported acts of sharing injection equipment with 833 injecting partners in the three months before baseline. Nearly half (41%) of modeled transmissions arose from fewer than 5% of participants in that period. Modeled transmissions per 1,000 PWID in that period were highest for severe depressive symptoms (100.4, 80.6–120.2) vs. mild (87.0, 68.2–109.4) or no symptoms (78.9, 63.4–94.1). Transmission estimates fell to near-zero at the 6-month visit. Conclusions Secondary transmissions were predicted to increase with depression severity, although most arose from a small number of participants. Our findings suggest that effective depression interventions could have the important added benefit of reducing HIV transmission among PWID. This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose

Depression, antiretroviral therapy initiation, and HIV viral suppression among people who inject drugs in Vietnam

Background: The burden of depression is high among people who inject drugs (PWID) and may contribute to the spread of HIV through poor treatment engagement and persistent viremia. We estimated the effects of depression on antiretroviral therapy (ART) initiation and viral suppression among PWID living with HIV. Methods: Longitudinal data were collected from 455 PWID living with HIV in Vietnam during 2009–2013. We estimated the 6- and 12-month cumulative incidence of ART initiation and viral suppression, accounting for time-varying confounding, competing events, and missing data. The cumulative incidence difference (CID) contrasted the incidence of each outcome had participants always vs. never experienced severe depressive symptoms across study visits to date. Results: Severe depressive symptoms decreased the cumulative incidence of ART initiation, with CID values comparing always vs. never having severe depressive symptoms of -7.5 percentage points (95% CI: -17.2, 2.2) at 6 months and -7.1 (95% CI: -17.9, 3.7) at 12 months. There was no appreciable difference in the cumulative incidence of viral suppression at 6 months (CID = 0.3, 95% CI: -11.3, 11.9) or 12 months (CID = 2.0, 95% CI: -21.8, 25.8). Limitations: Discrepancies between the ART initiation and viral suppression outcomes could be due to under-reporting of ART use and missing data on viral load. Conclusions: Future work probing the seemingly antagonistic effect of depression on treatment uptake – but not viral suppression – will inform the design of interventions promoting HIV clinical outcomes and reducing onward transmission among PWID