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Scholarly Works (16 results)

  • Thesis
  • Peer Reviewed
UC San Diego Electronic Theses and Dissertations (2022)

Abstract of the dissertation

Early infant male circumcision for HIV prevention in Uganda: determinants of uptake and future intentions; and exploration of health workers’ perspectives

by

Michael EdiauDoctor of Philosophy in Public Health (Global Health) San Diego State University 2022 University of California San Diego 2022

Professor Susan M. KieneBackground: World Health Organization (WHO) recommends early infant male circumcision (EIMC) for HIV prevention in countries with high HIV prevalence and low male circumcision (MC) coverage, like Uganda. This dissertation assessed the; effect of MC knowledge on EIMC (chapter 1) and theorized determinants of intention to circumcise male infants and associated moderators in central Uganda (chapter 2). It also explored health workers’ perspectives on EIMC in a traditionally non-circumcising community in northeastern Uganda (chapter 3). Methods: This was a cross-sectional survey of parents of male children aged 0–5 years from central Uganda (chapters 2 and 3). Multivariable logistic regression analysis was performed to determine correlates of male infant circumcision (chapter 2, n=1,831). The theory of planned behavior (TPB) predictors of intention to circumcise male children and potential moderators were assessed using PATH analyses (chapter 3, n=2,134). To explore health workers’ perspectives on EIMC (chapter 4), a qualitative descriptive study was conducted using in-depth interviews with health workers (n=26) in Soroti and Katakwi districts. Qualitative data were analyzed using thematic analysis. Results: The odds of having a circumcised male child were higher among parents who knew MC prevents HIV infection (aOR 1.77, 95% CI 1.57-1.98, p<0.001), circumcised fathers (aOR 1.87, 95% CI 1.68-2.08, p<0.001). TPB predictors of intention included attitude (Coeff=0.58, p=0.002) and PBC (Coeff=0.26, p=0.002). Gender and father’s circumcision status did not moderate any TPB relationship. Health workers who participated in EIMC welcomed it for its benefits and advantages, including being a simple procedure, fast wound health, and future HIV prevention. However, some health workers who had not participated in EIMC expressed concerns about EIMC, including the risk of injury and pain. EIMC facilitators included the provision of funding and health workers’ training on EIMC. Reported barriers included lack of funding and supplies as EIMC barriers since the provided support ended. Conclusion: Having knowledge of MC predicted male infant circumcision. Attitude and PBC towards EIMC predicted intention to circumcise male children. Donor funding availability facilitated EIMC, while its cessation was a barrier to EIMC delivery. EIMC programs should target knowledge, attitude, and behavioral control and ensure funding.

    • Thesis
    • Peer Reviewed
    UC San Diego Electronic Theses and Dissertations (2022)

    Background: The burden of HIV/AIDS continues to impact the health and wellbeing of people living with HIV (PLHIV) globally, and HIV prevalence rates remain disproportionately high in sub-Saharan Africa (SSA). HIV stigma, which can be examined through distinct mechanisms, is associated with less than favorable health outcomes and behaviors. Psychosocial factors and other forms of stigma can intersect with HIV stigma, concurrently contributing to HIV outcomes. Finally, how researchers measure and operationalize HIV stigma can significantly impact the way in which scientists view and discuss HIV stigma and its effects on health-related outcomes and behaviors. Objective: The overarching goal of the proposed dissertation is threefold: (i) examine how the co-occurrence of HIV- and mental health-related stigma is related to HIV testing behaviors, (ii) measure changes in HIV stigma immediately after diagnosis, and examine if disclosure, linkage to care, and other factors that may be associated with short term changes in HIV stigma after diagnosis, are associated with those changes, and (iii) assess psychometric properties of three discrete HIV stigma scales. Methods: This dissertation utilized data from the Providing Access to HIV Care (PATH)/Ekkubo Study. This is a cluster-randomized controlled trial, which compares the efficacy of an enhanced linkage to HIV care intervention versus the standard-of-care for individuals living in rural Uganda.(1) Aim one examined the co-occurrence of anticipated social HIV- and mental health-related stigma, among men and women reporting as HIV negative in the PATH/Ekkubo baseline dataset. Aim two made use of data collected at three time points among PATH/Ekkubo intervention participants: diagnosis (baseline), two-weeks post-diagnosis, and six-weeks post-diagnosis. Changes in anticipated, enacted, internalized, and overall HIV stigma were assessed statistically. Then, linkage to care and other psychosocial factors were explored as variables associated with statistically significant changes in HIV stigma. Finally, aim three utilized PATH/Ekkubo six-month follow-up data, collected from individuals who were newly diagnosed at baseline, and randomized into the control arm. Psychosocial properties were measured and examined for three distinct HIV stigma scales: anticipated, enacted, and internalized. Results: In aim one, the relationship between anticipated social HIV stigma and HIV testing behaviors was moderated by depression stigma for females, but not males. In aim two, both internalized and overall HIV stigma statistically significantly decreased in the six weeks post-initial HIV diagnosis among women, but not men. Further examination of psychosocial factors associated with these changes revealed that changes in both internalized and overall HIV stigma, over time, are moderated by disclosure status among women. In aim three, the three revised HIV stigma scales demonstrated good construct validity, strong internal reliability, and measured and performed similarly across genders. The revised enacted and internalized scales demonstrated strong external criterion validity. Conclusions: HIV stigma, an ever-evolving phenomenon, remains ubiquitous in areas with high HIV disease burden. Public health efforts must continue to find new ways in which HIV stigma is related to HIV health behaviors and outcomes, with special efforts made to modernize HIV stigma measurement tools.

      • Thesis
      • Peer Reviewed
      UC San Diego Electronic Theses and Dissertations (2017)

      Background: Ugandan fisherfolk are a priority population for the scale up of antiretroviral treatment (ART). However, a number of multi-level factors may pose a challenge to engaging this population in HIV care.

      Objectives: Our specific aims include: 1) examining the prevalence of substance use, and its effect on ART adherence; 2) exploring the role of norms of masculinity on men’s engagement in HIV care; and 3) identifying individual, interpersonal, normative environment, and physical/built environment-level determinants of HIV clinic attendance and ART adherence.

      Methods: A cross-sectional, mixed methods study design was employed with male fisherfolk on ART in Waksio District, Uganda. This study included a quantitative structured questionnaire (N=300), and qualitative in-depth interviews (n=30). Aim 1 uses both the quantitative and qualitative data. Aim 2 uses only qualitative data. Aim 2 uses only quantitative data.

      Results: We identified sub-optimal engagement in HIV care among men overall. Aim 1 demonstrated alcohol’s negative effect on ART adherence, and alcohol’s greater effect on non-adherence among men taking twice daily regimens compared to once daily. Aim 2 demonstrated HIV as a threat to men’s masculinity. However, ART’s positive effects on health restored men’s ability to fulfill their masculine roles, which motivated men for continued engagement in HIV care. Aim 3 identified multi-level factors associated with missed HIV clinic visits, including those at the individual (age), interpersonal (marital status), normative (anticipated HIV stigma), and physical/built environment-levels (travel time to the clinic, structural-barriers to adherence, accessing care on a landing site). Factors associated with ART non-adherence included those at the individual (age, income) and normative levels (anticipated and enacted HIV stigma).

      Conclusions: These findings highlight an urgent need for strategies to improve clinic attendance and ART adherence among male fisherfolk on ART, and add to our understanding of the multi-level determinants affecting HIV care engagement among male fisherfolk. We discuss public health implications, and suggest a package of interventions that may be integrated into differentiated service delivery specific to this most-at-risk population, including brief screening and intervention for alcohol reduction, gender transformative programming, and the integration of peer support and stigma reduction into community-based platforms for ART delivery.

        Cover page: Engagement in HIV Care among Male Fisherfolk in Uganda
        • Thesis
        • Peer Reviewed
        UC San Diego Electronic Theses and Dissertations (2023)

        Background: Although medical advancements have transformed the prognosis and increased the life expectancy of people living with HIV (PLHIV), the health-related quality of life (HRQOL) of these individuals remains suboptimal. Objectives: The aims of this dissertation are to: 1) assess the psychometric properties of Medical Outcome Survey-HIV (MOS-HIV), which is the most commonly used HRQOL measurement; 2) explore the multidimensional association of social support (emotional and instrumental) and HRQOL (physical and mental) among recently diagnosed PLHIV in rural Uganda; 3) investigate how social support can buffer the effects of co-occurring conditions of depression and drug use among PLHIV in urban United States. Methods: Aim 1 and Aim 2 used the 6-month follow-up data (n=480) from a cluster-randomized controlled trial that compared the efficacy of an enhanced linkage to HIV care intervention among PLHIV in rural Uganda. Aim 3 utilized the baseline data (n=1082) of a multisite US intervention to support employment and housing of PLHIV. Results: In Aim 1, psychometric assessment of the MOS-HIV subscale did not support unidimensionality and the use of sum scores. Then, physical and mental HRQOL index scores was measured using factor coefficients based on graded response models. Aim 2 findings highlight the importance of disaggregated dimensional measures revealing unique associations between social support dimensions and HRQOL indexes; instrumental social support was significantly associated with both physical and mental HRQOL, although the associations were masked for the aggregated overall social support measure. Further examination of these associations revealed that age and gender moderated the association between emotional social support and mental HRQOL indexes. Aim 3 findings showed that, in comparison to those with no depression and drug use, those with co-occurring conditions and depression were significantly more likely to have lower mental and physical HRQOL, but those with drug use exhibited no significant relationship with HRQOL. Conclusions: Our results highlight the importance of monitoring HRQOL among PLHIV using updated measurement tools and provide insights into how specific social support dimensions can be meaningful to target the unique needs of PLHIV sub-populations as they relate to age, gender, and co-occurring conditions.

          • Article
          • Peer Reviewed
          UCLA Previously Published Works (2022)
          Intimate partner violence (IPV) is associated with poor HIV care linkage and retention, medication adherence, and viral suppression. However, limited knowledge exists regarding potential mechanisms linking IPV to these outcomes. We aimed to (a) identify the top barriers to accessing HIV care experienced by women living with HIV (WLHIV) who report a history of IPV and have suppressed viral load (VL) versus unsuppressed VL and (b) understand how these barriers influence VL, comparing WLHIV with a history of IPV to WLHIV without a history of IPV. Study data come from newly diagnosed WLHIV in rural Uganda participating in the standard-of-care control arm of a randomized trial (n = 152). Descriptive results ranking mean scores from highest to lowest showed that, among women with a history of IPV, irrespective of viral suppression status, paying for transportation to come to clinic, having to wait at the clinic for long periods of time, and finding a clinic within reasonable travel distance were the top three barriers to accessing HIV care. WLHIV with a history of IPV were significantly more likely to have unsuppressed VL versus suppressed VL if they reported higher levels of difficulty finding a clinic within reasonable travel distance (RRR = 1.7, 95% CI [1.1-2.7]), getting permission to take time off from work (RRR = 1.5, 95% CI [1.0-2.9]), and finding time to come to the clinic for an appointment (RRR = 1.6, 95% CI [1.0-2.6]). The same relationships were not present among WLHIV without a history of IPV, suggesting these barriers and their effect on VL may be uniquely related to IPV. Interventions should address IPV and HIV care continuum outcomes in tandem, targeting barriers to accessing HIV care likely associated with IPV. Additional research is necessary to better understand how IPV relates to HIV care barriers and VL.
            Cover page: Perceived Barriers to HIV Care and Viral Suppression Comparing Newly Diagnosed Women Living with HIV in Rural Uganda with and without a History of Intimate Partner Violence
            • Article
            • Peer Reviewed
            UCLA Previously Published Works (2021)

            Background

            Harmful alcohol use is a leading cause of morbidity and mortality in sub-Saharan Africa (sSA); however, the effects of non-pharmacological alcohol interventions in this region are unknown.

            Design

            A systematic review and meta-analysis of the available literature through 14 March 2019 was undertaken. Two authors extracted and reconciled relevant data and assessed risk of bias. Meta-analyses were conducted. The review protocol is registered on International Prospective Register of Systematic Reviews (PROSPERO) (CRD42019094509).

            Setting

            Studies conducted in sSA were eligible for inclusion.

            Participants

            Individuals participating in interventions aimed at reducing alcohol use.

            Interventions

            Randomized and non-randomized controlled trials testing non-pharmacological interventions (psychosocial and structural) on alcohol consumption in sSA.

            Measurements

            Eligible outcomes included the Alcohol Use Disorders Identification Test (AUDIT) scores; alcohol abstinence; measures of drinking quantity and frequency; and biomarkers of alcohol consumption.

            Findings

            Nineteen intervention trials (18 reports) testing psychosocial interventions (no structural interventions included), judged of moderate quality, were included in meta-analyses. A beneficial effect was identified for psychosocial interventions on alcohol abstinence at 3-6 months [odds ratio (OR) = 2.05, 95% confidence interval (CI) = 1.20-3.48, k = 5, n = 2312, I2  = 79%] and 12-60 months (OR = 1.91, 95% CI = 1.40-2.61, k = 6, n = 2737, I2  = 63%) follow-up. There were no statistically significant effects found for AUDIT score [2-3 months: mean differences (MD) = -1.13, 95% CI = -2.60 to 0.34, k = 6, n = 992, I2  = 85%; 6 months: MD = -0.83, 95% CI = -1.92 to 0.26, k = 6, n = 1081, I2  = 69%; 12 months: MD = -0.15, 95% CI = -1.66 to 1.36, k = 4; n = 677; I2  = 75%], drinks per drinking day (3 months: MD = -0.22, 95% CI = -2.51 to 2.07, k = 2, n = 359, I2  = 82%; 6-36 months: MD = -0.09, 95% CI = -0.49 to 0.30, k = 3, n = 1450, I2  = 60%) or percentage of drinking days (3 months: MD = -4.60, 95% = -21.14 to 11.94; k = 2; n = 361; I2  = 90%; 6-9 months: MD = 1.96, 95% CI = -6.54 to 10.46; k = 2; n = 818; I2  = 88%).

            Conclusion

            Psychosocial interventions show promise at increasing self-reported alcohol abstinence in sSA, but clinical, methodological and statistical heterogeneity across meta-analytical outcomes suggests that results should be interpreted with caution.
              Cover page: Psychosocial interventions for reducing alcohol consumption in sub‐Saharan African settings: a systematic review and meta‐analysis
              • Article
              • Peer Reviewed
              UCLA Previously Published Works (2021)

              Introduction

              Antenatal alcohol use is linked to adverse maternal and neonatal outcomes. Uganda has one of the highest rates of alcohol use in sub-Saharan Africa, but the prevalence of antenatal alcohol use has not been reported in the Rakai region.

              Methods

              We used cross-sectional data from pregnant women in the Rakai Community Cohort Study between March 2017 and September 2018. Using bivariate and multivariable analyses, we assessed associations between self-reported antenatal alcohol use and sociodemographic characteristics, intimate partner violence (IPV), and HIV status.

              Results

              Among 960 pregnant women, the median age was 26 years, 35% experienced IPV in the past 12 months, 13% were living with HIV, and 33% reported alcohol use during their current pregnancy. After adjusting for marital status, education, smoking, and HIV status; Catholic religion (AOR: 3.54; 95% CI: 1.89-6.64; compared to other), bar/restaurant work (AOR: 2.40; 95% CI: 1.17-4.92; compared to agriculture), >one sex partner in past year (AOR: 1.92; 95% CI: 1.17-3.16), a partner that drank before sex in past year (AOR: 2.01; 95% CI: 1.48-2.74), and past year IPV (AOR: 1.55; 95% CI: 1.14-2.11) were associated with antenatal alcohol use.

              Conclusion

              We found that alcohol use during pregnancy was common and associated with religion, occupation, higher numbers of past year sex partners, having a partner who drank before sex in the past 12 months, and IPV experience. More research is needed to understand the quantity, frequency, and timing of antenatal alcohol use; and potential impacts on neonates; and to identify services that are acceptable and effective among pregnant women.
                Cover page: Alcohol use during pregnancy in Rakai, Uganda
                • Article
                • Peer Reviewed
                UC San Diego Previously Published Works (2021)

                Background and aims

                In Latin America, Mexico was first to launch a hepatitis C virus (HCV) elimination strategy, where people who inject drugs (PWID) are a main risk group for transmission. In Tijuana, HCV seroprevalence among PWID is > 90%, with minimal harm reduction (HR). We evaluated cost-effectiveness of strategies to achieve the incidence elimination target among PWID in Tijuana.

                Methods

                Modeling study using a dynamic, cost-effectiveness model of HCV transmission and progression among active and former PWID in Tijuana, to assess the cost-effectiveness of incidence elimination strategies from a health-care provider perspective. The model incorporated PWID transitions between HR stages (no HR, only opioid agonist therapy, only high coverage needle-syringe programs, both). Four strategies that could achieve the incidence target (80% reduction by 2030) were compared with the status quo (no intervention). The strategies incorporated the number of direct-acting anti-viral (DAA) treatments required with: (1) no HR scale-up, (2) HR scale-up from 2019 to 20% coverage among PWID, (3) HR to 40% coverage and (4) HR to 50% coverage. Costs (2019 US$) and health outcomes [disability-adjusted life years (DALYs)] were discounted 3% per year. Mean incremental cost-effectiveness ratios (ICER, $/DALY averted) were compared with one-time per capita gross domestic product (GDP) ($9698 in 2019) and purchasing power parity-adjusted per capita GDP ($4842-13 557) willingness-to-pay (WTP) thresholds.

                Results

                DAAs alone were the least costly elimination strategy [$173 million, 95% confidence interval (CI) = 126-238 million], but accrued fewer health benefits compared with strategies with HR. DAAs + 50% HR coverage among PWID averted the most DALYs but cost $265 million, 95% CI = 210-335 million). The optimal strategy was DAAs + 50% HR (ICER $6743/DALY averted compared to DAAs only) under the one-time per-capita GDP WTP ($9698).

                Conclusions

                A combination of high-coverage harm reduction and hepatitis C virus treatment is the optimal cost-effective strategy to achieve the HCV incidence elimination goal in Mexico.
                  • Article
                  • Peer Reviewed
                  UCLA Previously Published Works (2019)
                  This study explored the intersection of masculinity and HIV care engagement among fishermen and other male fisherfolk on antiretroviral therapy (ART) in Wakiso District, Uganda. We conducted 30 in-depth interviews with men on ART recruited from HIV treatment sites and used a thematic analysis approach. Since HIV diagnosis and ART initiation, men had adopted masculine identities more conducive to HIV care engagement. The masculine roles of worker and provider, husband and sexual partner and the appearance of physical strength were compromised by HIV, but restored by ART's positive effects on health. Peers also emerged as facilitators to HIV care, with men supporting each other to seek testing and treatment. However, structural and occupational barriers to HIV care associated with the masculine role of worker remained a barrier to care engagement. Findings suggest that emphasising the benefits of ART in bolstering men's ability to fulfil the roles important to them may improve the effectiveness of HIV testing and treatment messaging for men. Differentiated care models that address structural-level barriers to care, and community-level gender-transformative programming to help fishermen engage in HIV care, may be beneficial.
                    Cover page: Masculinity and engagement in HIV care among male fisherfolk on HIV treatment in Uganda
                    • Article
                    • Peer Reviewed
                    UC San Diego Previously Published Works (2021)

                    Background and aims

                    Syringe-sharing among people who inject drugs, which can occur during incarceration and post-release, has been linked with increased risk of blood-borne infections. We aimed to investigate the cumulative effect of repeated incarceration and the post-release period on receptive syringe-sharing.

                    Design

                    Ongoing community-based cohort, recruited through targeted sampling between 2011 and 2012 with 6-month follow-ups.

                    Setting

                    Tijuana, Mexico.

                    Participants

                    Sample of 185 participants (median age 35 years; 67% female) with no history of incarceration at study entry, followed to 2017.

                    Measurements

                    Cumulative incarceration and post-release period were constructed from incarceration events reported in the past 6 months for each study visit. Receptive syringe-sharing in the past 6 months was assessed as a binary variable. We used logistic regression with generalized estimating equations to examine the association between cumulative incarceration events and the post-release period with receptive syringe-sharing over time. Missing data were handled through multiple imputation.

                    Findings

                    At baseline, 65% of participants engaged in receptive syringe-sharing in the prior 6 months. At follow-up, 150 (81%) participants experienced a total of 358 incarceration events [median = 2, interquartile range (IQR) = 1-3]. The risk of receptive syringe-sharing increased with the number of repeated incarcerations. Compared with never incarcerated, those with one incarceration had 1.28 [95% confidence interval (CI) = 0.97-1.68] higher adjusted odds of syringe-sharing; two to three incarcerations, 1.42 (95% CI = 1.02-1.99) and more than three incarcerations, 2.10 (95% CI = 1.15-3.85). Participants released within the past 6 months had 1.53 (95% CI = 1.14-2.05) higher odds of sharing syringes compared with those never incarcerated. This post-release risk continued up to 1.5 years post-incarceration (adjusted odds ratio = 1.41, 95% CI = 1.04-1.91), but then waned.

                    Conclusions

                    A longitudinal community cohort study among people who inject drugs suggested that the effects of incarceration on increased injecting risk, measured through syringe-sharing, are cumulative and persist during the post-release period.
                      Cover page: Impact of cumulative incarceration and the post‐release period on syringe‐sharing among people who inject drugs in Tijuana, Mexico: a longitudinal analysis
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