Khameer Kidia

HIV is like a tsotsi. ARVs are your guns: associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa.

Objectives:WHO guidelines recommend disclosure to HIV-positive children by school age in order to improve antiretroviral therapy (ART) adherence. However, quantitative evidence remains limited for adolescents. This study examines associations between adolescent knowledge of HIV-positive status and ART-adherence in South Africa. Design:A cross-sectional study of the largest known community-traced sample of HIV-positive adolescents. Six hundred and eighty-four ART-initiated adolescents aged 10–19 years (52% female, 79% perinatally infected) were interviewed. Methods:In a low-resource health district, all adolescents who had ever initiated ART in a stratified sample of 39 health facilities were identified and traced to 150 communities [n = 1102, 351 excluded, 27 deceased, 40 (5.5%) refusals]. Quantitative interviews used standardized questionnaires and clinic records. Quantitative analyses used multivariate logistic regressions, and qualitative analyses used grounded theory for 18 months of interviews, focus groups and participant observations with 64 adolescents, caregivers and healthcare workers. Results:About 36% of adolescents reported past-week ART nonadherence, and 70% of adolescents knew their status. Adherence was associated with fewer opportunistic infection symptoms [odds ratio (OR) 0.55; 95% CI 0.40–0.76]. Adolescent knowledge of HIV-positive status was associated with higher adherence, independently of all cofactors (OR 2.18; 95% CI 1.47–3.24). Among perinatally infected adolescents who knew their status (n = 362/540), disclosure prior to age 12 was associated with higher adherence (OR 2.65; 95% CI 1.34–5.22). Qualitative findings suggested that disclosure was undertaken sensitively in clinical and family settings, but that adults lacked awareness about adolescent understandings of HIV status. Conclusion:Early and full disclosure is strongly associated with improved adherence amongst ART-initiated adolescents. Disclosure may be an essential tool in improving adolescent adherence and reducing mortality and onwards transmission.

Sex and secrecy: How HIV-status disclosure affects safe sex among HIV-positive adolescents

HIV-positive adolescents who engage in unsafe sex are at heightened risk for transmitting or re-acquiring HIV. Disclosure of HIV-status to sexual partners may impact on condom use, but no study has explored the effects of (i) adolescent knowledge of ones HIV-status, (ii) knowledge of partner status and (iii) disclosure to partners, on safer sex behaviour. This study aimed to identify whether knowledge of HIV-status by HIV-positive adolescents and partners was associated with safer sex. Eight fifty eight HIV-positive adolescents (10–19 years old, 52% female, 68.1% vertically infected) who had ever initiated antiretroviral treatment in 41 health facilities in the Eastern Cape, South Africa, were interviewed using standardised questionnaires. Quantitative analyses used multivariate logistic regressions, controlling for confounders. Qualitative research included interviews, focus group discussions and observations with 43 HIV-positive teenagers and their healthcare workers. N = 128 (14.9%) of the total sample had ever had sex, while N = 109 (85.1%) of sexually active adolescents had boy/girlfriend. In total, 68.1% of the sample knew their status, 41.5% of those who were sexually active and in relationships knew their partners status, and 35.5% had disclosed to their partners. For adolescents, knowing ones status was associated with safer sex (OR = 4.355, CI 1.085–17.474, p = .038). Neither knowing their partners status, nor disclosing ones HIV-status to a partner, were associated with safer sex. HIV-positive adolescents feared rejection, stigma and public exposure if disclosing to sexual and romantic partners. Counselling by healthcare workers for HIV-positive adolescents focused on benefits of disclosure, but did not address the fears and risks associated with disclosure. These findings challenge assumptions that disclosure is automatically protective in sexual and romantic relationships for HIV-positive adolescents, who may be ill-equipped to negotiate safer sex. There is a pressing need for effective interventions that mitigate the risks of disclosure and provide HIV-positive adolescents with skills to engage in safe sex.

‘I was thinking too much’: experiences of HIV‐positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe

To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings.

Cultural adaptation of a cognitive-behavioural intervention to improve adherence to antiretroviral therapy among people living with HIV/AIDS in Zimbabwe: Nzira Itsva

Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted for use in Africa. We selected, culturally adapted and tested the feasibility of a cognitive-behavioural intervention for adherence and for delivery in a clinic setting in Harare, Zimbabwe. The feasibility of the intervention was evaluated using a mixed-methods assessment, including ratings of provider fidelity of intervention delivery, and qualitative assessments of feasibility using individual semi-structured interviews with counsellors (n=4) and patients (n=15). The intervention was feasible and acceptable when administered to 42 patients and resulted in improved self-reported adherence in a subset of 15 patients who were followed up after 6months.

“We Are Not Really Marketing Mental Health”: Mental Health Advocacy in Zimbabwe

Introduction Few people with mental disorders in low and middle-income countries (LMICs) receive treatment, in part because mental disorders are highly stigmatized and do not enjoy priority and resources commensurate with their burden on society. Advocacy has been proposed as a means of building political will and community support for mental health and reducing stigma, but few studies have explored the practice and promise of advocacy in LMICs. Methods We conducted 30 semi-structured interviews with leaders in health and mental health in Zimbabwe to explore key stakeholder perceptions on the challenges and opportunities of the country’s mental health system. We coded the transcripts using the constant comparative method, informed by principles of grounded theory. Few interview questions directly concerned advocacy, yet in our analysis, advocacy emerged as a prominent, cross-cutting theme across participants and interview questions. Results Two thirds of the respondents discussed advocacy, often in depth, returning to the concept throughout the interview and emphasizing their belief in advocacy’s importance. Participants described six distinct components of advocacy: the advocates, to whom they advocate (“targets”), what they advocate for (“asks”), how advocates reach their targets (“access”), how they make their asks (“arguments”), and the results of their advocacy (“outcomes”). Discussion Despite their perception that mental health is widely misunderstood and under-appreciated in Zimbabwe, respondents expressed optimism that strategically speaking out can reduce stigma and increase access to care. Key issues included navigating hierarchies, empowering service users to advocate, and integrating mental health with other health initiatives. Understanding stakeholder perceptions sets the stage for targeted development of mental health advocacy in Zimbabwe and other LMICs.

The mental health of HIV-positive adolescents

In The Lancet Psychiatry, Khameer Kidia and colleagues propose that carefully selected and trained adolescents living with HIV can effectively help the delivery of mental health care for other adolescents living with HIV. We concur, and want to bring attention to a National Institute of Child Health and Human Developmentfunded project in Kigali, Rwanda, where we are doing exactly what Kidia and colleagues recommend: trained HIV-positive Rwandan youths deliver a trauma-informed cognitive behavioural intervention to improve adherence to antiretroviral therapy in young people with HIV. Since 2004, Women’s Equity in Access to Care and Treatment (WEACTx) has provided integrated primary care to women, men, and children with HIV. Psychosocial services and support groups are an essential component of culturally sensitive quality care. HIV-positive youths attend support groups to develop social support and gain knowledge about HIV. Since 2010, adolescents aged 19 years and older have been trained as so-called peer parents to help counsellors in leading activities and discussions with younger youths. After observing successful engagement of peer parents and youths, we developed a youth-led group-based intervention to improve medication adherence in 14–21-year-olds at WE-ACTx and University Teaching Hospital of Kigali (CHUK) youth programmes. In January, 2013, we initiated a randomised controlled trial to assess a six-session youth-led intervention to increase antiretroviral therapy adherence compared with usual care. Working closely with Rwandan mental health providers and adolescents living with HIV, a US-based psychologist adapted an evidence-based intervention for the Rwandan context. The intervention addresses knowledge about HIV; safer sex practices; stigma; gender-based violence; trauma; cognitive behavioural strategies that promote learning connections between thoughts, feelings, and behaviours; and problemsolving skills to resolve adherence obstacles. Movement-based relaxation techniques are also practiced. 18 youth leaders from peer parent groups were selected from the WEACTx and CHUK youth programmes. Rwandan-trained psychologists with BA qualifications were recruited to supervise the youth leaders. The USA-based psychologist provided 14 days of training for the youth leaders, assisted by the psychologists, to teach the curriculum, practice the intervention strategies, review group dynamics and leadership skills, and receive feedback to improve their facilitation. Ongoing supervision is provided by a cascade approach, in which the US psychologist has weekly Skype calls with the psychologists who then supervise the youth leaders twice per week. In-person consultations with youth leaders and psychologists take place biannually. At study midpoint (April 4, 2015), 198 youths have completed baseline assessments, of whom 99 remain in usual treatment and 99 in intervention groups. After the 6-month and 12-month assessments, participants will attend a youth-led booster session and will be re-assessed at 18 months. Fidelity data collected by self-reports and observer reports for ten groups showed good observance to and delivery of the curriculum. Therefore, our experience supports the idea that adolescents living with HIV can eff ectively and with fi delity lead mental health interventions for HIV-infected youths. We are encouraged by the enthusiasm, competence, and confidence of the youth leaders during their training and their skill as intervention facilitators. We believe that adolescents living with HIV will have an important role in improving HIV care for themselves and other aff ected youths.

Mental health in Zimbabwe: a health systems analysis

There has been little external analysis of Zimbabwes mental health system. We did a systems analysis to identify bottlenecks and opportunities for mental health service improvement in Zimbabwe and to generate cost-effective, policy-relevant solutions. We combined in-depth interviews with a range of key stakeholders in health and mental health, analysis of mental health laws and policies, and publicly available data about mental health. Five themes are key to mental health service delivery in Zimbabwe: policy and law; financing and resources; criminal justice; workforce, training, and research; and beliefs about mental illness. We identified human resources, rehabilitation facilities, psychotropic medication, and community mental health as funding priorities. Moreover, we found that researchers should prioritise measuring the economic impact of mental health and exploring substance use, forensic care, and mental health integration. Our study highlights forensic services as a central component of the mental health system, which has been a neglected concept. We also describe a tailored process for mental health systems that is transferable to other low-income settings and that garners political will, builds capacity, and raises the profile of mental health.

American Health Is Global Health

I am an international medical student with a preexisting health condition studying in New York. I have had excellent experiences with the U.S. health care system: Last year, I contrasted the tragic manner in which my father died of hypertrophic cardiomyopathy in Zimbabwe with the outstanding care I received in the United States for the same genetic disease (1). Today, as I create my rank order list for residency, I am less naively optimistic about the future than I was just a few months ago. My ability to provide and receive health care is now at risk. At the very time when population health in the United States has become fragile because of proposals to repeal the Patient Protection and Affordable Care Act, President Trumps stance on immigration ignores a global community of health specialists that could be of critical assistance to this country. As I prepare to enter internal medicine residency this Julywhere I will treat thousands of U.S. patientsmy immigration status is tenuous, my long-term commitment to global health is challenged, and my own health could be affected. There are substantial concerns about the future of H-1B visas: the most sought-after visa for international residents. A current bill in the U.S. House of Representatives, for example, proposes increasing the income floor for these visas to

HIV Status Disclosure to Perinatally-Infected Adolescents in Zimbabwe: A Qualitative Study of Adolescent and Healthcare Worker Perspectives

130000 (2). Because medical residents earn an average salary between

Barriers to provider-initiated testing and counselling for children in a high HIV prevalence setting: a mixed methods study.

50000 and