Browsing by Author "Dow, Dorothy"

Background: Despite improved access to HIV testing and medication, AIDS remains a leading cause of death among youth living with HIV (YLWH) in Tanzania. YLWH are prone to worse HIV outcomes than other age groups, which may be caused or mediated by mental health, social determinants of health (SDH), and adverse childhood experiences (ACEs). In this study, the investigators sought to determine if ACEs were correlated with key health variables in hopes of better understanding the factors associated with negative HIV and mental health outcomes among Tanzanian youth. Additionally, the investigators aimed to observe longitudinal trends in virologic suppression to understand the extent to which undetectable = untransmittable or “U=U” messaging applies to the more volatile youth demographic. Finally, the investigators sought to identify patterns and predictors that could aid in understanding risk of virologic failure in this population. Methods: The investigators incorporated and merged secondary data from participants who were enrolled in both of two distinct studies to create a longitudinal database spanning from 2013 to 2020. Participant ACE scores were derived from trauma exposure questionnaires and were compared with data about mental health, stigma, SDH, sexual experiences, self-reported adherence and HIV RNA (viral load). Associations of ACEs and other key variables were performed using linear regression. Results: ACEs were common among YLWH, especially loss of a parent and physical abuse. ACEs were also correlated with both mental health outcomes and virologic failure. Of the 48 participants who were virologically suppressed at the beginning of the study, one third had subsequent virologic failure, which was often associated with changes in ACEs, medication regimen, and SDH. Conclusion: Understanding common ACEs in this vulnerable population has direct relevance for the design of targeted interventions to prevent and treat repercussions of childhood trauma and improve mental health and HIV outcomes. ACEs, experiences with suicide risk, and low social support are important correlates of virologic failure and should be an alert when considering repeat HIV RNA testing and eligibility for supportive services.

Background: AIDS is the leading killer of adolescents in Africa, the continent most impacted by the AIDS pandemic. The East African nation of Tanzania is one of the top five countries with the highest burden of HIV in the world. Despite these challenges, scale up of anti-retroviral therapy (ART) has enabled millions of children infected with HIV to survive into adolescence and adulthood. These children attend family-centered and adolescent clinics where they not only receive HIV care, but also form close knit bonds with their healthcare providers and peers. As patients age into adulthood, they require to transition to the adult HIV clinic. Failure to transition results in an adolescent treatment bulge and strain on capacity in the family centered and adolescent clinics. This adolescent to adult transition period is a point of frequent loss to follow-up in the HIV care continuum, which may be partially due to fear and anxiety about the change. As clinics seek guidance on how best to manage the transition, few established protocols exist, and those available were primarily written for well-resourced settings. This study examined challenges and facilitators of the transition of care among youth living with HIV in Moshi, Tanzania.

Methods: Purposive sampling methods were used to recruit youth living with HIV who attended an adolescent specific clinic, Teen Club, and the adult HIV clinic at Kilimanjaro Christian Medical Centre. Two native Swahili speaking research assistants trained in qualitative research conducted in-depth interviews. Medical records were reviewed retrospectively to collect data on factors associated with HIV outcomes. Preliminary results were presented to key stakeholders. Youth and key stakeholders separately suggested solutions to identified challenges associated with transition of care. Results: 19 youth participated in the study. A slight majority were female (53%) and on first-line ART. Participants’ age of HIV diagnosis ranged from 5 to 18 years with a mean ART duration of 9.8 years. Barriers and facilitators of transition were categorized into four domains based on the Health Care Transition Research Consortium (HCTRC) framework. Individual domain: Barriers included long ART duration and financial constrains due to low socio-economic status. Facilitators to care were a positive perspective on living with HIV, high sense of maturity and responsibility, and good health maintenance. Family/Social Support Domain: Barriers were stigma and lack of social events in the adult clinic. Facilitators were family and peer support. Health care system domain: Barriers were lack of preparation for transition and concern about the quality of care in the adult clinic which entailed payment for services, few physicians, long waiting times and poor patient-provider communication. Environment domain: Barriers were lack of national guidelines for transition and inadequate investment in adolescent health and education by the government.

Conclusion: Transition is a complex, dynamic process influenced by many factors. With projections indicating that the number of youth living with HIV in Tanzania is likely to increase in the coming years, it is vital to develop a transition protocol that addresses the challenges identified and is feasible to implement in low resource settings. A strong protocol may influence the use of health system resources, facilitate continuity of care, and improve long term disease outcomes.

Six percent of the world’s population of youth living with HIV (YLWH) reside in Tanzania. Despite scale up of antiretroviral therapy (ART), poor ART adherence contributes to AIDS related morbidity and mortality in YLWH. Reasons for poor adherence include mental health challenges, HIV-related stigma, and lack of psychosocial support. Sauti Ya Vijana (SYV), a group-based, lay counselor delivered, 10-session mental health intervention for Tanzanian youth living with HIV was developed. The objective of this study was to describe the mental health outcomes of SYV in youth living with HIV.

This mixed-methods study enrolled 128 YLWH, aged 12-24, in Moshi, Tanzania to receive either the SYV intervention or treatment as usual. Youth in both arms completed structured questionnaires assessing their demographics, mental health and stigma symptoms, and self-reported ART adherence, at baseline, 6 months, 12 months, and 18 months study timepoints. A mixed effects linear regression model was used to analyze the change in stigma and mental health measures from baseline to the three follow-up timepoints. A subset of 10 youth who were randomized to the intervention arm completed semi-structured in-depth interviews at least one year after the intervention. Interviews were conducted in Kiswahili, and interview guide topics included participant description of history of depression symptoms, current challenges, recollection of specific SYV topics, and their experience during and after the SYV intervention. Interviews were transcribed and translated to English. Inductive thematic analysis using NVivo was used to analyze interview transcripts and identify common themes.

One hundred and five youth were randomized; 58 to the intervention arm and 47 to the treatment as usual arm. Average age of participants at baseline was 17.8 years and 49% of enrolled participants were male. Majority of the youth (86%) randomized to the intervention arm attended at least 8 out of 10 SYV sessions. The study was not powered to statistically detect treatment effect, but youth enrolled in both study groups showed improvement in their mental health and internal stigma measures at all follow-up timepoints in comparison to baseline. Ten youth, 18-25 years of age, were interviewed. Seven of the ten participants were male, and 60% were responders. All participants attended at least eight of the 10 intervention sessions and all baseline, 6 months, and 18-month follow-up appointments. Participants all reported experiencing intermittent symptoms of depression such as feelings of sadness. Current challenges included difficult interpersonal relationships and taking ART on time. The most memorable SYV lessons were coping skills such as breathing exercises. Participants described how SYV helped them have “more confidence”, accept themselves, and incorporate positive coping skills such as relaxation (deep breathing) when they felt stressed.

The findings provide evidence that providing a 10-session group based mental health intervention can have a long-term impact on the psychosocial outcomes of YLWH and can improve resilience in this population. Implementation of the SYV intervention into the routine HIV clinical care has promise to improve overall well-being of YLWH.

Background: Mental health challenges comprise a significant share of the global disease burden among adolescents. In many global settings, mental health services are limited and few adolescent mental health interventions (AMH) exist or have been sustained. This qualitative study sought to explore stakeholder perspectives on factors that influence sustainable implementation of AMH interventions in East and Southern Africa, and to explore youth leaders’ perspectives on and experiences with delivering a mental health intervention tailored to adolescents living with HIV in Tanzania. Methods: In-depth interviews lasting between 30-60 minutes were conducted virtually with 12 participants. One focus group discussion with six participants lasting 1.5 hours was conducted in Tanzania. Data were recorded and transcribed and then coded and analyzed using Nvivo 12 Pro software. Results: Sufficient political will, civil society involvement, multisectoral approaches, health system integration, and mental health awareness are important factors for sustainable implementation. Major constraints to sustainable implementation include the absence of these factors, as well as stigma, low mental health literacy, and insufficient funding and health system capacity. Conclusions: Mental health awareness, contextual fit, and the meaningful engagement of key stakeholders influences the sustainable implementation of AMH interventions. These findings have several important implications for policy and practice.

Background: Youth living with HIV have worse health outcomes compared to adults or children. Few interventions have been developed engaging youth in their care to promote resilience. Peer-led education is one potential way to boost confidence and bolster resilience while also improving HIV knowledge of youth living with HIV (YLHIV). Peer youth leaders (PYL) can be effective educators because they are seen as trustworthy and relatable to their peers. PYL themselves may also benefit from increased resilience and empowerment after taking on leadership position at their monthly adolescent HIV clinic. This study evaluated the acceptability, feasibility, and effectiveness of using PYL to teach an HIV education. Methods: Seven HIV-infected youth were recruited based on their previous enrollment in a mental health intervention for HIV-infected youth. Those who demonstrated confidence, excellent adherence, and upstanding behavior were chosen to become PYL. PYLs were trained by a doctor, social worker, and previously trained group leaders of a mental health intervention to teach an HIV education curriculum adapted from the Baylor International Pediatric AIDS Initiative. Trainings occurred once a week for two to three hours in preparation for teaching at the monthly adolescent HIV clinic. Two PYLs taught one-hour lessons to youth during the monthly adolescent HIV clinic. Approximately 25 clinic attendees were asked to volunteer to complete pre/post knowledge assessments and provided feedback on the PYL model. Acceptability and feasibility of using PYL to deliver an HIV curriculum to YLHIV was evaluated through attendance records, fidelity checklists and feedback notes that were documented by trained group leaders who supervised PYL curriculum delivery. In depth interviews were conducted to evaluate change in fears, motivations, and resilience among PYL before and after assuming the leadership role. PYL resilience was measured using the Connor-Davidson Scale at baseline (prior to starting the teaching role) and 6 months after initiating training. Results: A PYL model of delivering an HIV curriculum was both feasible and acceptable as reported by youth attending monthly adolescent HIV clinic and PYL. Qualitative findings showed peer education created safe discussion spaces, reduced stress of participants, and enhanced beliefs of importance in maintaining good adherence. HIV knowledge was improved as measured by self-report, and improvement did not meet statistical significant (p =0.057). PYL leaders demonstrated trends toward improved resilience as measured by Connor-Davidson Resilience Scale and increased confidence, feelings of self-worth, sense of purpose, social support, and optimism and decreased internal stigma based on in-depth interviews. Conclusions: Results demonstrated the PYL model of teaching an HIV curriculum was feasible and acceptable. PYL had improved resilience as a result of taking on a leadership role at their monthly adolescent HIV clinic. Future evaluation of YLHIV retention in care and health outcomes as a result of participation in the PYL education should be explored.

Gendered differences in HIV infection disproportionately impact adolescent girls and young women (AGYW), where adolescent girls are about six times more likely to become infected with HIV than adolescent boys in sub-Saharan Africa, and young people living with HIV are more likely to have adverse HIV and mental health outcomes compared to older individuals living with HIV. Furthermore, about half of adolescent pregnancies annually are unintended, and adolescent pregnancies are often rooted in similar structural causes of HIV, resulting in adverse health outcomes for AGYW and exacerbating adverse HIV-related health outcomes. To understand how to best support AGYW living with HIV (LWH) in fulfilling their intended goals, the aim of this study was to examine family planning knowledge, preference, and barriers and facilitators to obtaining preferred contraception among young women living with HIV (YWLWH) in the Kilimanjaro and Arusha Regions of Tanzania. Qualitative interviews, a focus group discussion, and a list ranking activity were conducted among 16 YWLWH. Individuals were purposely sampled into two groups: those who had a pregnancy experience (PE, n = 13) and those with no pregnancy experiences (NPE, n = 3) to compare the knowledge about, attitudes and norms around, perceptions of, preferences for, and experiences with family planning to better understand barriers and facilitators to engagement with desired family planning services. Analysis included inductive and deductive coding and memo writing. Seven of 13 participants experienced an unplanned first pregnancy, and male condoms (8/16) and the calendar method (7/16) were the most common contraceptives ever used by participants. No participants used a hormonal contraceptive method prior to their first pregnancy. Attitudes and perceived social norms around individuals who are perceived as appropriate users of family planning services, perceived side effects of contraceptives, along with an expressed lack of knowledge about contraceptives emerged as the most prevalent barriers to engagement with family planning services. Known and perceived benefits of contraceptive were the most salient facilitators of family planning engagement. The most prevalent barriers to desired engagement with family planning services could be addressed through education, a desire resoundingly expressed by participants. Possible avenues to increase potential impact of delivered educational interventions include leveraging close relationships and social networks to normalize adolescent engagement with clinical family planning services and deliver evidence-based education about contraception.

Background: Youth living with HIV (YLWH) face mental health challenges that negatively influence their adherence to antiretroviral medication and HIV outcomes. In sub-Saharan Africa, where the majority of YLWH reside, there are few mental health professionals. Task-shifting interventions to lay peer leaders may be an effective strategy for addressing mental health challenges. This study aims to understand and evaluate peer group leaders’ experiences delivering a peer-led, group-based mental health intervention called The Voice of Youth (Sauti ya Vijana (SYV) in Swahili) to YLWH in Tanzania. Methods: Peer group leaders (PGLs) aged 23 to 29 years and living with HIV were trained to deliver SYV. The study took place at four different sites in Tanzania. In-depth interviews (IDIs) were conducted with PGLs after delivering the SYV pilot study. IDIs were audio-recorded in Swahili and translated to English. English transcripts were analyzed using NVivo, and Excel was used to summarize data further and identify themes. Results: PGLs expressed a multitude of motivators and perceived benefits in their roles, including a desire to help youth, increased confidence, and a newfound hope for the future. Challenges included concerns about compensation and navigating exposure to difficult life events from the youth that triggers past trauma experience by PGLs. PGLs also shared recommendations for the intervention in terms of expansion and sustainability. Conclusions: Insights from the PGLs can help enhance the SYV PGL experience and position SYV for sustainability as Tanzania navigates scaling mental health care YLWH.

Background: Adolescence is a critical risk period for the onset of mental health difficulties. Youth living with HIV (YLWH) face additional challenges navigating peer and romantic relationships due to stigma and disclosure, putting youth more at risk for mental health difficulties. This study explored changes in resilience of youth enrolled in a mental health intervention by examining development protective factors to address challenges over a six-year period. Methods: YLWH in Moshi, Tanzania were recruited who enrolled in a mental health intervention, Sauti ya Vijana (SYV) and participated in an in-depth interview as a part of a prior needs assessment study, both of which also included demographic, mental health measures, and stigma measures. The first in-depth interview took place in 2013/2014; which was paired with a subsequent interview in 2020. Both interviews explored youth experiences with mental health, protective factors, and challenges. Resilience in respondents was defined as positive adaptations made in response to challenges. Results: Five youth completed in-depth interviews. Three participants were male; mean age of was 23.4 years (SD 0.9 years). PHQ9, SDQ, and UCLA scores decreased a average of 5.8 (SD 5.9), 9.4 (SD 5.7), and 6.0 points (SD 10.0), respectively; Berger stigma scores increased an average of 4.6 points (SD 5.4). The primary challenge youth described was stigma; the primary protective factor for resilience and mental health was social support. Conclusions: YLWH face many challenges; however, protective factors improved youth resilience to face these challenges. Youth need consistent support and resources as they transition into adulthood.