Ashraf Kagee

Development of a Brief Scale to Measure AIDS-Related Stigma in South Africa

Although there has been progress in AIDS stigma research, there are no multi-item AIDS stigma scales that have been shown reliable and valid in Africa. The current research reports the development of the nine-item AIDS-Related Stigma Scale. Research conducted in five South African communities (N = 2306) found the scale internally consistent, α = 0.75 and time stable over 3 months, r = 0.67. The scale was also reliable in three different languages (English, Xhosa, and Afrikaans). Correlations showed that the AIDS-Related Stigma Scale was moderately inversely correlated with years of education and AIDS knowledge. In addition, individuals who stated that HIV positive persons should conceal their HIV status had higher AIDS-Related Stigma Scale scores. Also supporting the scale’s construct validity, individuals who refused to report whether they had been tested for HIV scored higher on the AIDS-Related Stigma Scale.

Proposals for mental disorders specifically associated with stress in the International Classification of Diseases-11

Mental disorders specifi cally associated with stress are exceptional in needing external events to have caused psychiatric symptoms for a diagnosis to be made. The specialty of stress-associated disorders is characterised by lively debates, including about the extent to which human suff ering should be medicalised, and the purported overuse of the diagnosis of post-traumatic stress disorder (PTSD). Most common mental disorders are potentiated or exacerbated by stress and childhood adversity. Moreover, the subjective narratives of many people with mental disorders emphasise such external events. Clinicians might inadvertently gravitate towards diagnoses of disorders specifi cally associated with stress whenever a signifi cant stressor can be identifi ed, because this approach provides a way to understand the person’s experience of symptoms, as a function of external events, that is more likely to be acceptable to the person. What could be missed in such formulations is that mental disorders specifi cally associated with stress are characterised not only by an antecedent event, but also by a distinct clinical picture with core symptoms that diff er from those of other mental disorders. WHO is developing the International Classifi cation of Diseases, version 11 (ICD-11), which is scheduled for approval in 2015. WHO is also responsible for the Mental Health Gap Action Programme (mhGAP), intended to assist with scaling up of mental health care, particularly in low-income and middle-income countries. It has launched the mhGAP intervention guide, which provides assessment and management protocols for selected conditions in non-specialised health-care settings. In response to requests from health-care providers, WHO is developing a module for this guide with disorders specifi cally associated with stress that will use proposed ICD-11 defi nitions. These activities are also relevant to WHO’s role in development of mental health policies related to humanitarian crises. Changes in the category of mental disorders specifi cally associated with stress are important because of questions about the validity of surveys showing a high rate of these diagnoses in populations who have experienced natural or man-made disasters, and about whether these diag noses are clinically useful in terms of leading to feasible and eff ective treatment. People with these disorders seek help in many health settings globally. The high level of overlap and co-occurrence with other mental disorders often challenges mental health specialists, while general medical services often note co-occurring somatic problems. The ICD-11 Working Group on this topic was asked to review scientifi c evidence and other information about use, clinical utility (as termed by WHO), and experience with relevant ICD-10 diagnoses in various health-care settings; to review proposals for the American Psychiatric Asso ciation’s Diagnostic and Statistical Manual of Mental Disorders 5 (DSM-5) and consider how these may be suitable or useful for global applications; and to assemble proposals for ICD-11 with a focus on improving clinical utility. The Working Group has recommended a separate grouping of disorders specifi cally associated with stress for ICD-11, rather than combining them with anxiety disorders as in ICD-10 or DSM-IV. Disorders specifi cally associated with stress have two key characteristics: they are identifi able on the basis of diff erent psychopathology that is distinct from other mental disorders; and they arise in specifi c association with a stressful event or series of events. For each disorder in the grouping, the stressor is a necessary, although not suffi cient, causal factor. The stressor could range from negative life events within the normal range of experience (in the case of adjustment disorder) to traumatic stressors of exceptional severity (in the case of PTSD and complex PTSD). Among the controversies about existing formulations of PTSD are concerns about its overuse in populations exposed to natural or man-made disasters. One problem has been the application of the diagnosis when populations are still being actively exposed to extreme stressors—eg, continuing confl ict, uprooting to unsafe locations, or earthquake aftershocks—which makes differentiation between PTSD, adaptive fear reactions, and grief diffi cult, especially when the defi nition of PTSD includes non-specifi c symptoms. Moreover, there is a concern that an overemphasis on PTSD could contribute to clinicians failing to recognise other commonly occurring mental disorders, especially depression. Nonetheless, the appropriate use of a clearly defi ned PTSD category is one aspect of progress in evidencebased mental health care in humanitarian settings. The Working Group has recommended a refocus on the diagnosis of PTSD on three core elements, and removal of non-specifi c symptoms that are also part of other disorders. The proposed diagnostic guidelines need re-experiencing of the traumatic event, in which the event is not only remembered but experienced as occurring again; avoidance of reminders likely to produce re-experiencing of the traumatic event(s); and a perception of heightened current threat, as indicated by Lancet 2013; 381: 1683–85

Diagnosis and classification of disorders specifically associated with stress: proposals for ICD-11

The diagnostic concepts of post‐traumatic stress disorder (PTSD) and other disorders specifically associated with stress have been intensively discussed among neuro‐ and social scientists, clinicians, epidemiologists, public health planners and humanitarian aid workers around the world. PTSD and adjustment disorder are among the most widely used diagnoses in mental health care worldwide. This paper describes proposals that aim to maximize clinical utility for the classification and grouping of disorders specifically associated with stress in the forthcoming 11th revision of the International Classification of Diseases (ICD‐11). Proposals include a narrower concept for PTSD that does not allow the diagnosis to be made based entirely on non‐specific symptoms; a new complex PTSD category that comprises three clusters of intra‐ and interpersonal symptoms in addition to core PTSD symptoms; a new diagnosis of prolonged grief disorder, used to describe patients that undergo an intensely painful, disabling, and abnormally persistent response to bereavement; a major revision of “adjustment disorder” involving increased specification of symptoms; and a conceptualization of “acute stress reaction” as a normal phenomenon that still may require clinical intervention. These proposals were developed with specific considerations given to clinical utility and global applicability in both low‐ and high‐income countries.

Structural barriers to ART adherence in Southern Africa: Challenges and potential ways forward

Abstract Structural barriers to antiretroviral therapy (ART) adherence are economic, institutional, political and cultural factors, that collectively influence the extent to which persons living with HIV follow their medication regimens. We identify three sets of structural barriers to ART adherence that are salient in Southern Africa: poverty-related, institutional, and political and cultural. Examples of poverty-related barriers are competing demands in the context of resource-constrained settings, the lack of transport infrastructure, food insecurity, the role of disability grants and poor social support. Examples of institutional factors are logistical barriers, overburdened health care facilities, limited access to mental health services and difficulties in ensuring adequate counselling. Examples of political and cultural barriers are controversies in the provision of treatment for AIDS, migration, traditional beliefs about HIV and AIDS, poor health literacy and gender inequalities. In forging a way forward, we identify ways in which individuals, communities and health care systems may overcome some of these structural barriers. Finally, we make recommendations for further research on structural barriers to ART adherence. In all likelihood, enhancing adherence to ART requires the efforts of a variety of disciplines, including public health, psychology, anthropology, sociology and medicine.

Paediatric HIV/AIDS disclosure: towards a developmental and process-oriented approach

Abstract As antiretroviral therapy becomes more widely available in low-resource settings and children with HIV/AIDS live for longer periods, disclosure of HIV diagnosis to infected children is becoming increasingly important. This article reviews the current literature on HIV-related disclosure in light of theories of cognitive development, and argues for the adoption of a process-oriented approach to discussing HIV with infected children. Disclosure presents unique challenges to healthcare workers and caregivers of children with HIV/AIDS that include controlling the flow of information about the childs HIV status to him/her and deciding on what is in his/her best interest. Health care workers’ and caregivers’ views regarding disclosure to children may often be contradictory, with healthcare workers likely to support disclosing the diagnosis of HIV/AIDS to children and caregivers more reluctant to discuss the disease with them. There is a clear need for practical interventions to support paediatric HIV disclosure which provide children with age-appropriate information about the disease.

Condom Use Among South African Adolescents: Developing and Testing Theoretical Models of Intentions and Behavior

We developed and tested models of intentions and behavior among adolescents from Cape Town, South Africa. Data from 261 participants who completed an initial measure of attitudes, beliefs, and prior behavior were used to develop a model of intentions to use condoms based on the Theory of Planned Behavior (TPB) and additional constructs found to be important in previous research with adolescents. Of the initial sample, 227 (87%) completed a behavioral follow-up 4 months later, and approximately one-third of those (n=72; 44 boys and 30 girls) reported having had sex in the prior 4 months. Data from this smaller sample were used to develop a model of condom use behavior based on intentions (as per the TPB) and the additional sub-population relevant constructs. Analyses generally supported the validity of the TPB in this context for predicting intentions and behavior. HIV knowledge and positive outlook (self-esteem and future optimism) were significantly related to TPB predictors of intentions. Intentions, acceptance of sexuality, and gender were significant predictors of behavior. Implications for the status of the TPB and the design of interventions for South African adolescents are discussed.

Structural barriers to adherence to antiretroviral therapy in a resource-constrained setting: the perspectives of health care providers

Abstract The present study examined the chief structural barriers to antiretroviral treatment (ART) adherence from the perspective of health care workers who provide treatment to patients living with HIV and AIDS in South Africa. The main barrier to adherence as identified by participants in the study was the stigma associated with living with HIV, and thus with receiving AIDS treatment. A second barrier was the fact that some patients willfully decide to forgo treatment so that they could retain state disability benefits associated with a low CD4 count. Other barriers included the lack of finances for transport to clinics and food insecurity, especially when medication needed to be taken with food. These barriers to ART adherence are conceptualized in terms of Bronfenbrenners Ecological Systems Theory.

Symptoms of depression and anxiety among a sample of South African patients living with HIV

Abstract Little systematic research has been conducted on the extent of psychiatric disorders among South African patients in general, and among patients living with HIV in particular. The present study reports on a survey conducted among 85 patients receiving treatment at three HIV clinics in the Western Cape. Participants completed the Hopkins Symptom Checklist (HSCL) and the Beck Depression Inventory (BDI), two self-report instruments designed to measure mood disturbance. The mean score of the sample on the HSCL was 47.54, which was significantly different from the commonly used cut-point of 44 for clinically significant distress; 52.9% of the sample scored in the elevated range on this measure. On the BDI, 37.6% of the sample fell in or above the moderate range for depression. The results suggest that a considerable proportion of the sample may be experiencing psychiatric difficulty, for which they may not be receiving treatment.

Lifetime and HIV-Related PTSD Among Persons Recently Diagnosed with HIV

This cross-sectional study sought to determine the percentage of individuals who met criteria for lifetime PTSD and HIV-related PTSD among 85 recently diagnosed HIV-positive patients attending public health clinics in the Western Cape, South Africa. The PTSD module of the Composite International Diagnostic Interview (CIDI) was used to determine the percentage of those who met criteria for lifetime PTSD and HIV-related PTSD. The rate of lifetime PTSD and incidence of HIV-related PTSD was 54.1% (95% CI: 43.6–64.3%) and 40% (95% CI: 30.2–50.6%), respectively. Findings suggest that receiving an HIV-positive diagnosis and/or being HIV-positive may be considered a stressor that frequently results in HIV-related PTSD. Given the various barriers to efficient mental health interventions and services in South Africa, there are significant challenges that need to be addressed in order to ensure that the mental health of HIV-positive individuals is appropriately addressed.

Screening for common mental disorders in low resource settings: reasons for caution and a way forward

Recognition of high rates of common mental disorders in many resource-constrained contexts has indicated the need for routine screening of patients attending public health facilities. Screening may facilitate entry into community level psychiatric services for those identified as disordered. Yet, screening instruments will need to ensure high specificity so as to minimise expenditures on treating false positives. Task shifting of screening activities to primary health care staff and lay workers in low income settings may hold some population- level advantages, including greater population coverage, more efficient deployment of health care staff, and the reduction of stigma if specific conditions are met.