Catherine Oswald

Mental Health Response in Haiti in the Aftermath of the 2010 Earthquake: A Case Study for Building Long-Term Solutions

&NA; Significant challenges exist in providing safe, effective, and culturally sound mental health and psychosocial services when an unforeseen disaster strikes in a low‐resource setting. We present here a case study describing the experience of a transnational team in expanding mental health and psychosocial services delivered by two health care organizations, one local (Zanmi Lasante) and one international (Partners in Health), acting collaboratively as part of the emergency response to the 2010 Haiti earthquake. In the year and a half following the earthquake, Zanmi Lasante and Partners in Health provided 20,000 documented individual and group appointments for mental health and psychosocial needs. During the delivery of disaster response services, the collaboration led to the development of a model to guide the expansion and scaling up of community‐based mental health services in the Zanmi Lasante health care system over the long‐term, with potential for broader scale‐up in Haiti. This model identifies key skill packages and implementation rules for developing evidence‐based pathways and algorithms for treating common mental disorders. Throughout the collaboration, efforts were made to coordinate planning with multiple organizations interested in supporting the development of mental health programs following the disaster, including national governmental bodies, nongovernmental organizations, universities, foreign academic medical centers, and corporations. The collaborative interventions are framed here in terms of four overarching categories of action: direct service delivery, research, training, and advocacy. This case study exemplifies the role of psychiatrists working in low‐resource settings as public health program implementers and as members of multidisciplinary teams.

Perceived discrimination and stigma toward children affected by HIV/AIDS and their HIV-positive caregivers in central Haiti

Abstract In many settings worldwide, HIV-positive individuals have experienced a significant level of stigma and discrimination. This discrimination may also impact other family members affected by the disease, including children. The aim of our study was to identify factors associated with stigma and/or discrimination among HIV-affected youth and their HIV-positive caregivers in central Haiti. Recruitment of HIV-positive patients with children aged 10–17 years was conducted in 2006–2007. Data on HIV-related stigma and/or discrimination were based on interviews with 451 youth and 292 caregivers. Thirty-two percent of caregivers reported that children were discriminated against because of HIV/AIDS. Commune of residence was associated with discrimination against children affected by HIV/AIDS and HIV-related stigma among HIV-positive caregivers, suggesting variability across communities. Multivariable regression models showed that lacking social support, being an orphan, and caregiver HIV-related stigma were associated with discrimination in HIV-affected children. Caregiver HIV-related stigma demonstrated a strong association with depressive symptoms. The results could inform strategies for potential interventions to reduce HIV-related stigma and discrimination. These may include increasing social and caregiver support of children affected by HIV, enhancing support of caregivers to reduce burden of depressive symptoms, and promoting reduction of HIV-related stigma and discrimination at the community-level.

Disclosure and Impact of Maternal HIV+ Serostatus on Mothers and Children in Rural Haiti

Mothers living with HIV (MLWHs) in the United States have reported that one of their main challenges is the decision to disclose their HIV serostatus to their children and the potential consequences of their disclosure. Little is known about the experiences of MLWHs regarding disclosing their HIV serostatus to their children and the impact of maternal HIV serostatus disclosure in the island nations of the Caribbean. Study objectives were to identify the factors influencing maternal HIV serostatus disclosure, examine the breadth of maternal HIV serostatus, and understand the impact of disclosure on mothers and the children. Baseline interviews were conducted between 2006 and 2007 with 25 HIV-positive mothers and 26 children ages 10–17 participating in a pilot psychosocial support intervention for HIV-affected youth and their caregivers in Haiti. Interviews were transcribed verbatim and coded for topical themes by two investigators. Analysis of the interviews yielded several themes relevant to reasons for disclosure, including children’s experience of HIV stigma in the community, social support and encouragement from psychosocial intervention workers. The main themes related to breadth of disclosure were brief disclosure and explicit disclosure with some mothers sharing information about how they learned about their illness diagnosis and their medication. Themes related to impacts of disclosure included emotional reactions of children and mothers, and children’s desire to assist mothers with illness and become involved. These findings suggest the need to provide more psychosocial support to HIV-affected families in the Caribbean region.

Risk and protective factors for internalizing and externalizing outcomes among HIV-affected youth in Haiti

The present study aims to: (1) estimate the levels of internalizing symptoms and externalizing behaviors among youth affected by HIV in central Haiti; and (2) examine the risk and protective factors associated with these outcomes to identify potential areas of intervention for HIV-affected youth. Baseline data for 492 youth affected by HIV (ages 10–17) and their 330 caregivers were collected for a pilot study of a psychosocial support intervention. Participants were recruited from a list of HIV-positive patients receiving care at Partners In Health/Zanmi Lasante clinic sites. Internalizing and externalizing behaviors were assessed using the Strengths and Difficulties Questionnaire. Demographic, economic, and social indicators were collected using a structured questionnaire administered by trained social workers. Youth affected by HIV in central Haiti displayed high levels of internalizing and, to a lesser degree, externalizing symptoms. Multivariate regression analysis demonstrated risk factors most strongly associated with internalizing symptoms (socioeconomic status, parental depressive symptoms) and externalizing behaviors (household living arrangements, such as living with a stepparent). Social support had a protective effect on externalizing behaviors for both caregiver (β = –0.03, p = 0.01) and self-report (β = –0.05, p < 0.0001). High levels of psychological distress were observed in this population, especially with respect to internalizing outcomes. Interventions should address the economic security, mental health, and access to antiretroviral therapy for families affected by HIV, as well as emphasize the importance of building supportive caregiver–child relationships to decrease the psychological symptoms and impact of other life stressors experienced by youth affected by HIV in Haiti and similar resource-limited settings.

Impact of community-based adherence support on treatment outcomes for tuberculosis, leprosy and HIV/AIDS-infected individuals in post-Ebola Liberia

ABSTRACT Background: Partners In Health (PIH) committed to improving health care delivery in Maryland County, Liberia following the Ebola epidemic by employing 71 community health workers (CHWs) to provide treatment support to tuberculosis (TB), HIV and leprosy patients. PIH simultaneously deployed a socioeconomic assistance program with three core components: transportation reimbursement to clinics; food support; and additional social assistance in select cases. Objective: This study aimed to evaluate how a CHW program for community treatment support and addressing socioeconomic barriers to care can impact patient outcomes in a post-conflict and post-epidemic context. Methods: Retrospective observational study utilizing registry data from 513 TB, 447 HIV and 75 leprosy patients at three health facilities in Maryland County, Liberia. Treatment coverage and clinical outcomes for patient cohorts enrolled in the pre-intervention period (January 2015 to June 2015) and the post-intervention period (July 2015 to July 2017) are compared using logistic regression analyses. Results: TB treatment coverage increased from 7.7% pre-intervention to 43.2% (p < 0.001) post-intervention and lost to follow-up (LTFU) rates decreased from 9.5% to 2.1% (p = 0.003). ART treatment coverage increased 3.8 percentage points (p = 0.03), with patient retention improving 63.9% to 86.1% (p < 0.001); a 6.0 percentage point decrease in HIV LTFU was also observed (p = 0.21). Despite an 84.3% treatment success rate observed for leprosy patients, pre-intervention data was largely unavailable and statistical significance could not be reached for any treatment outcomes pre-post intervention. Conclusions: The PIH approach to CHW community treatment support in Liberia demonstrates how, with the right inputs, excellent clinical outcomes are possible even in post-conflict and post-epidemic contexts. Care should be taken to position and support CHWs so that they have the opportunity to succeed, including full integration and recognition within the system, and the addition of clinical system improvements and social supports that are too often dismissed as unsustainable.

P2-S9.07 Economic risk factors for syphilis infection among pregnant women in rural Haiti

Background Of the 12 million global adult syphilis infections occurring globally each year, syphilis disproportionately affects women in low-income countries. WHO estimates about 80% of syphilis positive pregnancies go untreated, often in Latin America and Africa. Economic and socio-structural characteristics may explain some of the vulnerability for infection. We studied the association between social and health services factors and syphilis in Haiti, a poor country with a high burden of infection. Methods We used data collected for a clinic-based case-control study of pregnant women attending general care womens clinics in rural Haiti from June 1999—to March 2001. Syphilis serostatus was determined by RPR test. Women were surveyed on socio-demographic and economic factors, access to healthcare, and sexual and gynaecological history. We performed multivariate analysis in SAS to identify factors associated with syphilis seropositivity and present results on two models. Results The 596 women studied were typically young, rural, and lived in poverty. Syphilis and HIV seropositivity were 5.5% and 4.3%, respectively. In model 1 (n=396), factors associated with maternal syphilis infection were: household monthly per capita income <75 goud (

Psychosocial support intervention for HIV-affected families in Haiti: Implications for programs and policies for orphans and vulnerable children

20 USD) (OR 2.4, 95% CI 0.9 to 6.6), having a 1 room house (OR 5.2, 95% CI 1.6 to 17.0), and history of prior pregnancy resulting in premature birth (OR 5.1, 95% CI 2.0 to 13.0). In model 2 (n=417), having fields where family members plant crops was a protective factor (OR 0.26, 95% CI 0.074 to 0.92), while reporting problems obtaining education (OR 3.2, 95% CI 1.1 to 7.7), <15 years of age at first intercourse (OR 2.9, 95% CI 1.1 to 7.7), history of an STD (OR=11.0, 95% CI 3.2 to 40.0), and vaginal discharge with odour (OR 3.4, 95% CI 1.1 to 11.0) were associated with maternal syphilis infection see Abstract P2-S9.07 Table 1. Abstract P2-S9.07 Table 1 Multiple logistic regression analysis of factors associated with maternal syphilis status of women in rural Haiti OR (95% CI) Model 1 (n=396)  Monthly per capita income less than 75 goud/person 2.4 (0.9 to 6.5)  House has 1 room only 5.2 (1.6 to 17.0)  ≤15 years old at first sexual intercourse 1.8 (0.7 to 4.5)  History of premature birth 5.1 (2.0 to 13.0) Model 2 (n=417)  Has fields where family members plant crops 0.26 (0.1 to 0.9)  House has 1 room only 1.6 (0.4 to 6.3)  Has problems with education 3.2 (1.1 to 9.3)  ≤15 years old at first sexual intercourse 2.9 (1.1 to 7.7)  More than 1 lifetime sexual partner 1.1 (0.4 to 3.2)  Had sexual intercourse with someone she knows or suspects had an STD 2.9 (0.3 to 30.0)  History of an STD 11 (3.2 to 40.0)  Vaginal discharge with a bad smell 3.4 (1.1 to 11.0)  Travels to clinic or health center by bus 1.8 (0.6 to 5.3)  Has more difficulties getting to usual health center or clinic during rainy season compared to dry season 0.4 (0.2 to 1.2) Discussion Among pregnant women in Haiti, some economic characteristics were predictors of vulnerability for syphilis infection and may help explain the inequitable distribution of syphilis disease burden. Further study is warranted to understand specific economic or other structural factors that may affect syphilis infection in women and may be amenable to intervention.