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Depression and HIV Pre-exposure Prophylaxis Use Among Sub-Saharan African Women

Depression and HIV Pre-exposure Prophylaxis Use Among Sub-Saharan African Women
Author: Jennifer Velloza
Publisher:
Total Pages: 140
Release: 2019
Genre:
ISBN:
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Daily, oral pre-exposure prophylaxis (PrEP) with emtricitabine/tenofovir disoproxil fumarate (FTC/TDF) is a highly efficacious HIV prevention strategy for key populations at high risk of HIV, including women, in sub-Saharan Africa. However, open-label studies and demonstration projects have reported that young women have difficulty adhering to PrEP over time, which limits its effectiveness as a prevention option. PrEP projects are now exploring modifiable barriers to adherence among women to maximize its public health benefit as it is being rapidly rolled out worldwide. Mental health factors, including depression, traumatic stress symptoms, and stigma, are highly prevalent among women at high risk of HIV acquisition and are barriers to medication use and health promotion behaviors. However, there has been little consideration until now of how such factors might also influence PrEP adherence among women in sub-Saharan Africa. The aims in this dissertation attempt to fill this research gap by: 1) exploring the impact of depressive symptoms on PrEP adherence among women; 2) examining the mechanisms by which depressive symptoms influence PrEP adherence; 3) describing the broader context of HIV-related stigma and empowerment on PrEP use; and 4) integrating depression screening into HIV care delivery to improve mental health and HIV outcomes. Two studies have examined the influence of depression on PrEP adherence and found that depressive symptoms have a negative effect on daily PrEP use for transgender women and men who have sex with men. Ours is the first study to examine links between depression and PrEP adherence among cisgender women in sub-Saharan Africa. We used marginal structural models to estimate the association between depressive symptoms and PrEP adherence while adjusting for time-varying confounding by sexual behavior, stigma, and social support. We found that probable depression was significantly associated with poor PrEP adherence among women, but not men, suggesting that mental health and depression experiences have differential impact on HIV prevention behaviors by gender. This work also led to questions about the mechanism of this association and whether there were important mediators of the relationship between depression and PrEP adherence that could explain at least some of this total effect. We conducted a mediation analysis using marginal structural models to estimate the controlled direct effect of depression on PrEP adherence, after accounting for the potentially mediating influence of HIV-related stigma, social support, and optimism about PrEP effectiveness. We found a significant negative direct influence of depression on PrEP adherence but this relationship was not strongly mediated by other psychosocial factors. Future research is needed to explore additional potential mediators of this relationship and identify areas for intervention. Qualitative research methods allow us to explore narratives around PrEP use, experiences of stigma, and concerns about mental health that are not captured by quantitative data. We analyzed serial in-depth interview data from a cohort of young women using PrEP to understand the broader context around their pill-taking, mental health, and relationships. In this study, we found that women described experiences of HIV-related stigma when they began taking PrEP which influenced their ability to take PrEP and their feelings about themselves. However, over time, women became more empowered to use PrEP and combat HIV-related stigma by becoming "ambassadors" of PrEP in their communities. This work highlights the potential for empowerment-based interventions to improve PrEP adherence and reduce community stigma and the richness of serially collected qualitative data. In Aims 1-3, we found evidence of a strong negative impact of depression on PrEP adherence and high rates of depression among women at risk of HIV. This work suggests that integrated depression screening and treatment with HIV prevention service delivery could improve mental health outcomes and PrEP effectiveness for women. To support the design of future integrated interventions, we conducted cognitive interviews assessing comprehensibility and acceptability of a widely used depression screening tool in the context of a PrEP delivery intervention among pregnant and postpartum women in Thika, Kenya. We found that the tool was largely acceptable and well-understood, but several minor changes to item wording and instructions would improve symptom screening and linkage to mental health care. These changes are part of our recommendations for the future use of this tool. The collective results presented in this dissertation illustrate the negative influence of depression and related psychosocial factors on consistent PrEP use for women, opportunities for stigma-reduction and empowerment-based intervention approaches to improve mental health symptoms and PrEP use in this population, and the potential to administer depression screening within the context of HIV prevention service delivery. This work contributes to a better understanding of the links between mental health and HIV risk for women and highlights the importance of integrating mental health and empowerment-based interventions with PrEP delivery to improve mental health screening and treatment and PrEP effectiveness for women in sub-Saharan Africa.

PrEP (pre-exposure Prophylaxis) Adherence Among East African Women

PrEP (pre-exposure Prophylaxis) Adherence Among East African Women
Author: Maria Pyra
Publisher:
Total Pages: 69
Release: 2018
Genre:
ISBN:
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HIV incidence remains disproportionately high for women, particularly young women, in Sub-Saharan Africa; women are also at heightened risk while pregnant, which may account for a substantial portion of their adult lives. Although HIV pre-exposure prophylaxis (PrEP) in pill form is known to be efficacious for women, there remain unanswered questions about adherence in open-label and real-world settings, as well as regarding the effectiveness of PrEP during pregnancy. In the work presented in this dissertation, we first examined how women used PrEP in an open-label demonstration project and particularly, how adherence was related to HIV risk behaviors. Second, to better assess adherence, we evaluated the sensitivity and specificity of a biomarker among East African men and women using PrEP. Finally, we examined the effect of pregnancy on PrEP concentrations. First, we found that women in known serodiscordant relationships were able to take PrEP effectively; more than half took PrEP during their entire risk period, with ≥6 doses for most weeks when on PrEP. HIV incidence was reduced 93% (95% CI 77%-98%) for all women and 91% (95% CI 29%-99%) among women under 25 years old. In further analysis, we found evidence of four adherence trajectories and two risk behavior trajectories over the first six months of PrEP use. Women with a declining risk behavior trajectory were more likely to have a declining adherence trajectory, while women with steady risk were more likely to have high steady adherence; this supports the idea of prevention-effective adherence, which optimizes PrEP use. In the second aim, we found low sensitivities for the adherence biomarker tenofovir-diphosphate, using thresholds established in U.S. populations. Adherence counseling based on biomarkers should carefully consider the trade-offs between sensitivity and specificity. Finally, we found that concentrations of PrEP are significantly lower in pregnant women compared to non-pregnant women, as well as during pregnancy compared to pre-pregnancy, after adjusting for adherence. Additional pharmacology and epidemiology studies are needed to determine if PrEP dosing should be altered to sustain systemic levels of tenofovir during pregnancy.

Disease Control Priorities, Third Edition (Volume 6)

Disease Control Priorities, Third Edition (Volume 6)
Author: King K. Holmes
Publisher: World Bank Publications
Total Pages: 1027
Release: 2017-11-06
Genre: Medical
ISBN: 1464805253
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Infectious diseases are the leading cause of death globally, particularly among children and young adults. The spread of new pathogens and the threat of antimicrobial resistance pose particular challenges in combating these diseases. Major Infectious Diseases identifies feasible, cost-effective packages of interventions and strategies across delivery platforms to prevent and treat HIV/AIDS, other sexually transmitted infections, tuberculosis, malaria, adult febrile illness, viral hepatitis, and neglected tropical diseases. The volume emphasizes the need to effectively address emerging antimicrobial resistance, strengthen health systems, and increase access to care. The attainable goals are to reduce incidence, develop innovative approaches, and optimize existing tools in resource-constrained settings.

HIV/AIDS in South Africa 25 Years On

HIV/AIDS in South Africa 25 Years On
Author: Poul Rohleder
Publisher: Springer Science & Business Media
Total Pages: 396
Release: 2009-09-01
Genre: Medical
ISBN: 1441903062
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Much has happened since the first appearance of AIDS in 1981: it has been identified, studied, and occasionally denied. The virus has shifted host populations and spread globally. Medicine, the social sciences, and world governments have joined forces to combat and prevent the disease. And South Africa has emerged as ground zero for the pandemic. The editors of HIV/AIDS in South Africa 25 Years On present the South African crisis as a template for addressing the myriad issues surrounding the epidemic worldwide, as the book brings together a widely scattered body of literature, analyzes psychosocial and sexual aspects contributing to HIV transmission and prevention, and delves into complex intersections of race, gender, class, and politics. Including largely overlooked populations and issues (e.g., prisoners, persons with disabilities, stigma), as well as challenges shaping future research and policy, the contributors approach their topics with rare depth, meticulous research, carefully drawn conclusions, and profound compassion. Among the topics covered: The relationship between HIV and poverty, starting from the question, "Which is the determinant and which is the consequence?" Epidemiology of HIV among women and men: concepts of femininity and masculinity, and gender inequities as they affect HIV risk; gender-specific prevention and intervention strategies. The impact of AIDS on infants and young children: risk and protective factors; care of children by HIV-positive mothers; HIV-infected children. Current prevention and treatment projects, including local-level responses, community-based work, and VCT (voluntary counseling and testing) programs. New directions: promoting circumcision, vaccine trials, "positive prevention." South Africa’s history of AIDS denialism. The urgent lessons in this book apply both globally and locally, making HIV/AIDS in South Africa 25 Years On uniquely instructive and useful for professionals working in HIV/AIDS and global public health.

Delivery of Antiretroviral Pre-exposure Prophylaxis for HIV Prevention in Pregnant and Postpartum Women

Delivery of Antiretroviral Pre-exposure Prophylaxis for HIV Prevention in Pregnant and Postpartum Women
Author: Jillian Pintye
Publisher:
Total Pages: 94
Release: 2017
Genre:
ISBN:
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Women in sub-Saharan Africa have substantial risk of acquiring HIV acquisition during and soon after pregnancy. Additionally, acute HIV infection among pregnant and breastfeeding women poses a double burden in that acute maternal HIV accounts for nearly one-third of all mother-to-child transmissions of HIV (MTCT). To reach global targets for elimination of MTCT and HIV prevention for mothers, it is critical to integrate effective primary HIV prevention strategies into maternal and child health (MCH) services. Tenofovir disoproxil fumarate (TDF)-based pre-exposure prophylaxis (PrEP) prevents HIV infection in adherent women. The World Health Organization (WHO) recommends PrEP for all individuals, including pregnant and breastfeeding women, at substantial HIV risk (defined as HIV residence in regions where HIV incidence is >3%). Programmatic delivery of PrEP for pregnant women is currently being considered in high-prevalence regions, though implementation approaches that efficiently optimize the benefit of PrEP during pregnancy have not been defined. Additionally, although WHO guidelines support PrEP use in pregnancy, national committees have differed in their conclusions. For example, PrEP use during pregnancy is supported by Kenyan antiretroviral guidelines but the lack of complete safety data led PrEP to be contraindicated for pregnant women in the current South African PrEP guidelines. As countries expand programmatic delivery of PrEP to pregnant women, it is important to understand motivations and beliefs for using PrEP during pregnancy to address concerns unique to this population. The studies within this dissertation address the implementation science gaps described above for the delivery of PrEP for HIV prevention to pregnant and postpartum in sub-Saharan Africa. To inform efficient PrEP delivery models, we present an empiric risk score for identifying pregnant and postpartum Kenyan women at highest risk for HIV acquisition who would mostly benefit from PrEP while reducing unnecessary exposure among low-risk women. Using data that could be easily collected in standard MCH clinic settings without additional laboratory diagnostics, our risk score identified 56% of pregnant women who acquired HIV among just 16% of women. Using register data from 62 antenatal MCH facilities throughout Kenya, we further estimated the absolute number and proportion of HIV-uninfected pregnant women in Kenya who could be offered PrEP under different public health approaches, including offering PrEP universally or based on either regional HIV prevalence and/or individual-level HIV risk factors. We found that offering PrEP only to pregnant women in the region with highest HIV prevalence (Nyanza) would reduce PrEP use among low-risk women by 74%, but exclude 63% of women with high risk for HIV based on individual-level characteristics nationally. To complement service delivery data, we also assessed experiences of using PrEP during pregnancy among HIV-uninfected Kenyan women in HIV-serodiscordant couples who became pregnant while using PrEP. The personal experiences of women with direct exposure to PrEP during pregnancy offers valuable insights for informing development of effective PrEP messaging strategies and programs. Finally, we evaluate whether adverse perinatal outcomes were more frequent in a cohort of Kenyan and Ugandan HIV-infected women who used TDF-containing antiretroviral therapy (ART) during pregnancy compared to HIV-infected women who used ART during pregnancy that did not contain TDF. Our findings support the growing evidence that prolonged prenatal TDF use is not associated with adverse perinatal outcomes and contribute to the few prospective studies evaluating the safety of TDF use during pregnancy from African cohorts. The studies within this dissertation aim to address these implementation science gaps and inform optimal and effective delivery of PrEP for HIV prevention to pregnant and postpartum in sub-Saharan Africa.

Improving Pre-exposure Prophylaxis Delivery for Young Women in Kenya

Improving Pre-exposure Prophylaxis Delivery for Young Women in Kenya
Author: Valentine Adhiambo Wanga
Publisher:
Total Pages: 82
Release: 2020
Genre:
ISBN:
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The rollout of pre-exposure prophylaxis (PrEP) for HIV prevention to priority populations, including young women, is expanding in sub-Saharan Africa. However, existing barriers to PrEP rollout at the individual, community and policy levels could slow progress and impede the success of PrEP implementation programs. In order to achieve success in HIV prevention, it is crucial to address these barriers, particularly among young women, a population especially vulnerable to HIV. In this dissertation, we evaluated the links among risk perception, sexual behavior and PrEP adherence in serodiscordant couples, evaluated the impact of incorporating HIVST in PrEP delivery for young women and assessed the cost of delivering PrEP to young women. In Aim 1, we used data from HIV-negative adults enrolled in a study of PrEP and antiretroviral therapy for HIV-serodiscordant couples in Kenya and Uganda to examine associations between: 1) condom use and risk perception and 2) risk perception and PrEP adherence. In Aim 2, we offered HIV self-testing (HIVST) to young women enrolled in a PrEP implementation study in two family planning clinics and assessed satisfaction with HIV testing and clinic experience, and the impact of HIVST on PrEP delivery procedures. In Aim 3, using the same population as that in Aim 2, we used micro-costing methods to estimate the incremental cost of delivering PrEP to young women. We found that sexual behavior aligned with perceived HIV risk, which can facilitate an HIV-negative individual's decisions about PrEP use. Additionally, we found HIVST to be feasible and acceptable for young women using PrEP, highlighting the need to evaluate its utility to streamline PrEP delivery and provide more testing options for young women on PrEP. Lastly, using practical data from PrEP implementation, we estimated the cost of delivering PrEP to young women, providing valuable data to inform budget impact and cost-effectiveness analyses as well as local resource allocation for scale-up of PrEP delivery to young women. Collectively, these studies addressed some of the barriers to PrEP delivery, proposed solutions to these barriers and drew attention to priority research needs for PrEP delivery to young women.

HIV Prevalence and HIV-related Risk Factors Among Women Living in Sub-Saharan Africa : a Literature Review ; The Association Between Depressive Symptoms, Anxiety, Alcohol Use and Interpersonal Violence Among HIV-infected Women in Western Kenya

HIV Prevalence and HIV-related Risk Factors Among Women Living in Sub-Saharan Africa : a Literature Review ; The Association Between Depressive Symptoms, Anxiety, Alcohol Use and Interpersonal Violence Among HIV-infected Women in Western Kenya
Author: Stella W. Kiarie
Publisher:
Total Pages: 76
Release: 2014
Genre: HIV infections
ISBN:
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Opportunity in Crisis

Opportunity in Crisis
Author:
Publisher: UNICEF
Total Pages: 68
Release: 2011
Genre: Health & Fitness
ISBN: 9280645862
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Today, around the world, there are 5 million young men and women living with HIV. Opportunity in Crisis: Preventing HIV from early adolescence to young adulthood examines the state of the HIV epidemic among young people, highlighting the challenges they face and presenting solutions informed by evidence of what works with different age groups and in different epidemic settings. The report outlines key steps towards building a continuum of HIV prevention that can help keep children HIV-free as they develop into young adults.

Behavior Change and Other Factors Related to HIV Transmission Among Female Sero-converters in Microbicide Trials

Behavior Change and Other Factors Related to HIV Transmission Among Female Sero-converters in Microbicide Trials
Author: Jennie Lee McKenney
Publisher:
Total Pages: 97
Release: 2015
Genre:
ISBN:
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HIV/AIDS continues to be a major public health problem throughout the world. In 2011, 23.5 million people were living with HIV/AIDS worldwide, with the greatest burden of disease in Africa, representing 2/3 of the total HIV/AIDS population. Specifically, sub-Saharan Africa bears the highest burden of the disease, with 22.9 million people living with HIV/AIDS (PLWHA), 60% of the total infections worldwide. Furthermore, within this region, women are disproportionately affected, accounting for 58% of people living with HIV/AIDS. 1 With the continued high prevalence and incidence of HIV among women, despite an increase in prevention interventions, including pre-exposure prophylaxis (PrEP), suggests behavior change still plays a key role in transmission. This dissertation aims to seek to understand high-risk sexual behaviors and other factors associated with an increased risk of secondary transmission among women in order to inform the implementation of new HIV prevention strategies and reduce the burden of HV. Chapter 1 is a brief introduction into HIV and the high-risk sexual behaviors that affect its transmission. Chapter 2 is based on data from a cohort study of recently sero-converted women from the Microbicide Trials Network (MTN) and demonstrated that depression plays a significant role in the acquisition of STIs. Chapter 3 is based on data from a cohort study of recently sero-converted women from the MTN and demonstrated that there are several factors that influence disclosure and timing of disclosure of HIV status. Chapter 4 is based on data from a cohort study of recently sero-converted women from the MTN and demonstrated that high-risk sexual behaviors are still frequent among HIV-infected women, and that ART may modify the risk of high-risk sexual behaviors. Finally, Chapter 5 is a brief discussion of results as well as their implications for future research.