Naoko Ishikawa

Perceived social support and the psychological well-being of AIDS orphans in urban Kenya.

Parental deaths due to AIDS seriously affect the psychological well-being of children. Social support may provide an effective resource in the care of vulnerable children in resource-limited settings. However, few studies have examined the relationships between social support and psychological well-being among AIDS orphans. This cross-sectional study was conducted to explore associations between perceived social support (PSS) and the psychological well-being of AIDS orphans, and to identify socio-demographic factors that are associated with PSS. Data were collected from 398 pairs of AIDS orphans (aged 10–18 years) and their caregivers in Nairobi, Kenya. The participants provided information on their socio-demographic characteristics, the childrens PSS, and the childrens psychological status (based on measures of depressive symptoms and self-esteem). Of the 398 pairs, 327 were included in the analysis. PSS scores of AIDS orphans showed significant correlations with depressive symptoms (ρ =−0.31, p<0.001) and self-esteem (ρ=0.32, p<0.001). Socio-demographic factors, such as HIV-positive status of children (β=3.714, p=0.014) and cohabitation with siblings (β=3.044, p=0.016), were also associated with higher PSS scores. In particular, HIV-infected children (n=37) had higher scores of PSS from a special person (β=2.208, p=0.004), and children living with biological siblings (n=269) also had higher scores of PSS from both a special person (β=1.411, p=0.029) and friends (β=1.276, p=0.039). In conclusion, this study showed that PSS is positively associated with the psychological well-being of AIDS orphans. Siblings and special persons can be effective sources of social support for AIDS orphans, which help to promote their psychological well-being.

Adherence to antiretroviral therapy (ART) during the early months of treatment in rural Zambia: influence of demographic characteristics and social surroundings of patients

BackgroundAround 70% of those living with HIV in need of treatment accessed antiretroviral therapy (ART) in Zambia by 2009. However, sustaining high levels of adherence to ART is a challenge. This study aimed to identify the predictive factors associated with ART adherence during the early months of treatment in rural Zambia.MethodsThis is a field based observational longitudinal study in Mumbwa district, which is located 150 km west of Lusaka, the capital of Zambia. Treatment naive patients aged over 15 years, who initiated treatment during September-November 2010, were enrolled. Patients were interviewed at the initiation and six weeks later. The treatment adherence was measured according to self-reporting by the patients. Multiple logistic regression analysis was performed to identify the predictive factors associated with the adherence.ResultsOf 157 patients, 59.9% were fully adherent to the treatment six weeks after starting ART. According to the multivariable analysis, full adherence was associated with being female [Adjusted Odds Ratio (AOR), 3.3; 95% Confidence interval (CI), 1.2-8.9], having a spouse who were also on ART (AOR, 4.4; 95% CI, 1.5-13.1), and experience of food insufficiency in the previous 30 days (AOR, 5.0; 95% CI, 1.8-13.8). Some of the most common reasons for missed doses were long distance to health facilities (n = 21, 53.8%), food insufficiency (n = 20, 51.3%), and being busy with other activities such as work (n = 15, 38.5%).ConclusionsThe treatment adherence continues to be a significant challenge in rural Zambia. Social supports from spouses and people on ART could facilitate their treatment adherence. This is likely to require attention by ART services in the future, focusing on different social influences on male and female in rural Zambia. In addition, poverty reduction strategies may help to reinforce adherence to ART and could mitigate the influence of HIV infection for poor patients and those who fall into poverty after starting ART.

The attitudes of primary schoolchildren in Northern Thailand towards their peers who are affected by HIV and AIDS

Abstract After more than a decade of the AIDS epidemic in Thailand, the number of children whose parents are living with HIV or have died from AIDS is increasing significantly and it has been reported that these children are often discriminated against by their peers. In order to better understand the current situation and to explore possible strategies to support HIV-affected children, this study examined childrens attitudes towards HIV and AIDS using questionnaires and focus group discussions with children in Grades three–six in five primary schools in a northern province in Thailand. A total of 513 children (274 boys and 239 girls) answered the questionnaire and five focus groups were organised. The findings showed a strong positive correlation between childrens belief that HIV could be transmitted through casual contact and their negative attitudes towards their HIV-affected peers. Most children overestimated the risk of HIV transmission through casual contact and this made their attitudes less tolerant and less supportive. After HIV prevention education (which included information on HIV transmission routes) was given in three of the study schools, the same questionnaire and focus groups were repeated and the findings showed that childrens attitudes had become more supportive. These findings suggest that HIV prevention education delivered through primary schools in Thailand can be an effective way to help foster a more supportive and inclusive environment and reduce the stigma and discrimination that decrease educational access and attainment for HIV-affected schoolchildren.

Paediatric HIV and elimination of mother-to-child transmission of HIV in the ASEAN region: a call to action

Abstract Recent achievements in scaling up paediatric antiretroviral therapy (ART) have changed the life of children living with HIV, who now stay healthy and live longer lives. However, as it becomes more of a chronic infection, a range of new problems have begun to arise. These include the disclosure of HIV serostatus to children, adherence to ART, long-term toxicities of antiretroviral drugs and their sexual and reproductive health, which are posing significant challenges to the existing health systems caring for children with HIV with limited resources, experiences and capacities. While intensified efforts and actions to improve care and treatment for these children are needed, it is crucial to accelerate the prevention of mother-to-child transmission (PMTCT) of HIV, which is the main cause of paediatric HIV in the ASEAN region so as to eliminate the fundamental cause of the problem. This report argues that given over 70% of women have access to at least one antenatal care visit in the region and acceptance of HIV testing after receiving counselling on PMTCT could be as high as 90%, there is an opportunity to strengthen PMTCT services and eventually eliminate new paediatric HIV infections in the ASEAN countries.

Psychological well-being and adherence to antiretroviral therapy among adolescents living with HIV in Zambia

ABSTRACT Physical and psychosocial changes during adolescence could influence the psychological well-being and adherence to antiretroviral therapy (ART) of adolescents living with HIV. However, few studies have assessed these two important issues in Zambia. This study aimed at addressing this gap by examining adolescents’ depressive symptoms and ART adherence. This was a mixed-methods study conducted from April to July 2014. We recruited 200 adolescents, ages 15 to 19, who were already aware of their HIV status. We measured depressive symptoms using the short form of the Center for Epidemiologic Studies Depression Scale, and self-reported three-day adherence to ART. We performed logistic regression analysis to identify factors associated with depressive symptoms and non-adherence to ART. For qualitative data, we examined challenges over ART adherence using thematic analysis. Out of 190 adolescents, 25.3% showed high scores of depressive symptoms. Factors associated with depressive symptoms were unsatisfactory relationships with family (Adjusted Odds Ratio [AOR] 3.01; 95% Confidence Interval [CI] 1.20–7.56); unsatisfactory relationships with health workers (AOR 2.68; 95% CI 1.04–6.93); and experience of stigma (AOR 2.99; 95% CI 1.07–8.41). Of all participants, 94.2% were taking ART, but 28.3% were non-adherent. Factors associated with non-adherence to ART were loss of a mother (AOR 3.00; 95% CI 1.05–8.58) and lack of basic knowledge about HIV (AOR 3.25; 95% CI 1.43–7.40). Qualitative data identified the following challenges to ART adherence: management of medication, physical reactions to medicine, and psychosocial distress. The evidence suggests that depressive symptoms and non-adherence to ART were priority issues in late adolescence in Zambia. Health workers should be aware of these issues, and the care and treatment services should be tailored to respond to age-specific needs.

Adolescents’ Experiences and Their Suggestions for HIV Serostatus Disclosure in Zambia: A Mixed-Methods Study

Background HIV serostatus disclosure is an immense challenge for adolescents living with HIV, their caregivers, and health workers. In Zambia, however, little guidance is available from the adolescents’ point of view on the HIV disclosure process. Objective This study aimed to examine the setting of HIV serostatus disclosure for adolescents, its impacts on them, and their suggestions on the best practice of HIV disclosure. Methods We conducted a mixed-methods study at the University Teaching Hospital in Zambia from April to July 2014. We recruited 200 adolescents living with HIV, aged 15–19 years. We collected data using a structured questionnaire including two open-ended questions. We excluded two adolescents due to withdrawal during the survey, and eight from the data set due to out-of-eligibility criteria in age. Eventually, we included 190 in the analysis. We performed descriptive analysis to calculate the distributions of basic characteristics of the adolescents, their experience and preference on HIV serostatus disclosure, its emotional and behavioral impacts, and health education topics they had ever learned at hospital. We performed thematic analysis with open-ended data to explain first impressions upon disclosure in detail and to determine perceived advantages of HIV serostatus disclosure. Results The majority of adolescents recommended the age of 12 as appropriate for adolescents to learn about their HIV serostatus and preferred disclosure by both parents. Out of 190 adolescents, 73.2% had negative or mixed feelings about HIV serostatus disclosure, while 86.2% reported that disclosure was beneficial. Thematic analyses showed that the adolescents reacted emotionally due to an unexpected disclosure and a belief of imminent death from HIV. However, they improved adherence to treatment (84.7%), limited self-disclosure of their HIV serostatus to others (81.1%), and felt more comfortable in talking about HIV with their caregivers (54.2%). Thematic analysis identified perceived benefits of disclosure as follows: better understanding of their sickness and treatment, and improved self-care and treatment adherence. Lower percentage of the adolescents have learned about psychosocial well-being, compared to facts about HIV and treatment. Conclusion Despite initial emotional distress experienced after the disclosure, knowing one’s own HIV serostatus was found to be a crucial turning point for adolescents to improve motivation for self-care. HIV serostatus disclosure to adolescents requires follow-up support involving parents/primary caregivers, health workers, and peers.

Nevirapine prophylaxis during breastfeeding

www.thelancet.com Vol 379 May 12, 2012 1787 DVT from mid-thigh level and up. Hence our patients are likely to have had a higher risk of post-thrombotic syndrome, which is refl ected in the relatively high frequency of this event noted in CaVenT. Hence, the eff ect size in the studies of elastic com pression stockings does not necessarily apply to our study. Additional issues to consider when inferring from these studies are their open design (both) and the non-validated defi nition of postthrombotic syndrome in one. Second, although an association between anticoagulation quality and post-thrombotic syndrome was shown in one study, no association was found in a similar one. In both studies, anticoagulation was given for 3 months initially and the eff ect on post-thrombotic syndrome might be mediated through an increased rate of recurrent venous thrombosis due to suboptimum anticoagulation therapy. We agree that time in the therapeutic range would have been a better indicator of anticoagulation quality. Finally, both elastic com pression stockings and CDT are treatments that are unlikely to be well assessed in a double-blind trial design. In response to Saurav Chatterjee and Abhishek Sharma, it is our opinion that one regional centre doing the procedures might have done better overall than the others. By tradition in Norway, CDT is done by interventional vascular radiologists, although currently there is no formal training for subspecialties within radiology. CDT was established at all four interventional centres for several years before the CaVenT study, and we did not look into team or individual performance, but agree that there is a learning curve for interventions in general and that possible diff erences could have been assessed as a substudy. Safety was a secondary outcome, but no bleeding complications were noted in the control group in the acute phase. The sample size would need to be larger to obtain a robust estimate of the complication rates including numbers needed to harm. Details of the technical aspects of the CDT procedures including adjunctive balloon angioplasty and stent insertion will be presented in a subsequent paper and were not included in this report, which focused on the clinically relevant outcomes. Finally, we are currently doing an economic evaluation of CDT.

AF1 Evaluation of AIDSRelief Facilitiesʼ Implementation of 2007 HIV Treatment Regimens After Introduction of the New Guidelines

BackgroundIn 2007, Zambias national Antiretroviral Therapy (ART) program revised the treatment protocols that were introduced in 2004, to more efficacious first line regimens with reduced toxicities and better resistance mutation profiles, thereby preserving drug options for second line treatment. The change in protocols introduced tenofovir as the preferred first line nucleotide reverse transcriptase inhibitor (NRTI) and Abacavir as the alternative NRTI for patients initiating treatment. It moved stavudine and zidovudine to second line, with phased out recommendation of stavudine 40 mg BID. MethodologyA review of the program data collected from all 19 AIDSRelief (AR) sites using a regimen data abstraction sheet provided by the national ART program was done from January 1, 2008 to March 31, 2011. ResultsOf the 13,584 adult patients on ART at the end of 2007 and within 6 months of introduction of the new standard treatment protocols, 22.5% of all adult patients on therapy received the new recommended treatment protocol for first line therapy. Of these, almost all (99.3%) received the preferred first NRTI drug. By the end of December 2008, 13,603 patients were newly enrolled onto ART, and of these, 29.2% was according to the national protocol. Currently 74% of patients enrolled onto first line ART in AR sites receive the recommend national treatment regimens. The program successfully phased out stavudine 40 mg BID by early 2009. DiscussionImplementation of new treatment protocols in AR sites is ongoing and a lag of more than three years is evident. Future research is needed to determine effective dissemination and implementation of new recommendations at facility level, to ensure the best treatment options are available as soon as possible and to evaluate the impact of the implementation delay on patient level outcomes, and national ART drug funding and procurement policies.