Faculty Bibliography

OBJECTIVES:We examined the impact of a family-based economic empowerment intervention on viral suppression and mental health among ALHIV. STUDY DESIGN:Between 2013 and 2014, 702 participants aged 10-16, living with HIV, and taking antiretroviral therapy, were recruited from 39 clinics in Uganda. Twenty clinics (n = 358 participants) were randomized to the intervention and 19 clinics (n = 344 participants) were randomized to the control conditions. The intervention comprised a matched savings account, financial literacy training, and microenterprise workshops. The primary outcome was viral suppression, while the secondary outcomes included depression, hopelessness, and self-concept. We ran mixed-effects models to determine the intervention effects. RESULTS:(5) = 27·26, p < 0·001], suggesting beneficial intervention effect for this demographic. CONCLUSIONS:Family EE interventions have the potential to improve viral suppression and mental health outcomes among ALHIV. These findings offer insights in designing programs and policies to improve outcomes among ALHIV.

Reliable and valid assessment tools are crucial for measuring alcohol use expectancies (AUE) among youth living with HIV (YLHIV). In this paper, we assess the psychometric properties of the original 17-item East Africa Alcohol Expectancy Scale (AFEXS) among Ugandan YLHIV-a scale developed and validated by Woolf-King et al. for use among Uganda adults living with HIV. Specifically, we applied the measure to a sample of 100 Ugandan YLHIV enrolled in a substance use intervention. To analyze the psychometric properties, we conducted exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and convergent validity analyses. The resulting 15-item youth AFEXS scale differed from the 11-item adult version. The 15-item Youth AFEXS demonstrated high internal consistency (α = 0.85), aligning with theoretical expectations of a three-factor structure related to sexual expectancies (7 items; α = 0.89), negative expectancies (4 items; α = 0.72), and release of inhibition expectancies (4 items; α = 0.77). The global scale and sub-scales demonstrated satisfactory convergent validity through positive correlations measures of frequency of alcohol consumption in the past 12 months: global AFEXS (r = 0.617; p = 0.000), sexual expectancies (r = 0.583; p = 0.000), negative expectancies (r = 0.618; p = 0.000), and release expectancies (r = 0.596; p = 0.000). The study confirms the youth AFEXS as a reliable and valid tool for assessing AUE among Ugandan YLHIV.

INTRODUCTION/BACKGROUND:. METHODS AND ANALYSIS/METHODS:or an enhanced usual care control arm. Couples in the Mlambe arm will receive incentivised matched savings accounts and monthly sessions on financial literacy, relationship skills, and alcohol reduction education and counselling. Participants will be assessed at baseline, 11 months, 15 months and 20 months to examine effects on heavy alcohol use, HIV viral suppression, ART adherence and couple relationship dynamics. Study hypotheses will be tested using multilevel regression models, considering time points and treatment arms. Programmatic costs will be ascertained throughout the study and incremental cost-effectiveness ratios will be computed for each arm. ETHICS AND DISSEMINATION/BACKGROUND:The RCT has been approved by the University of California, San Francisco (UCSF) (Human Research Protection Program; Protocol Number 23-40642), and the study has been approved by the National Health Sciences Research Committee (NHSRC; Protocol Number 24/05/4431) in Malawi. Adverse events and remedial actions will be reported to authorities both in Malawi and at UCSF. Results will be disseminated to study participants, local health officials and HIV policy makers and through presentations at conferences and publications in peer-reviewed journals. TRIAL REGISTRATION NUMBER/BACKGROUND:ClinicalTrials.gov Protocol Registration; NCT06367348 registered on 19 April 2024; https://register. CLINICALTRIALS/RESULTS:gov/. Protocol Version 1.0: 22 October 2024.

BACKGROUND:In many Sub-Saharan African countries (SSA), including Uganda, adolescent girls, especially those from low-income families, are disproportionately affected by inadequate menstrual hygiene management (MHM) facilities and supplies. This study assesses the impact of two interventions, including economic empowerment and family-strengthening interventions, on the self-esteem of adolescent girls and explores the moderating effects of cultural attitudes and menstrual hygiene knowledge. METHODS:We analyzed longitudinal data from a 3-arm Cluster Randomized Control Trial, Suubi4Her study, with a follow-up period of 24 months (2018-2022). A total of 1260 adolescent girls, aged 14-17 years, and living within a family were recruited from 47 schools within five geopolitical districts in Southwestern Uganda. The three study arms were: control (n = 16 schools, n = 408 students), Economic Empowerment using incentivized youth development accounts (YDA) (n = 16 schools, n = 471 students), and YDA + a family strengthening intervention that uses Multiple Family Group (MFG) meetings to address adolescent girls' and family health and wellbeing (n = 15 schools, n = 381 students). We used mixed-effect linear regression models to assess the impact of economic empowerment on self-esteem, measured by the Rosenberg Self-Esteem Scale, and the moderation effect of menstrual hygiene knowledge, measured by a nine-item scale, and cultural attitudes, measured by self-reported school absence during menstrual periods. RESULTS:(4) = 12.99, p = 0.011). Pairwise group comparisons at the different assessment time points showed no significant differences in self-esteem between YDA group and the control at baseline (β = 0.173 (-1.453, 1.108), p = 0.791), at 12 months (β = 0.372 (-0.893, 1.637), p = 0.565), and at 24 months (β = 0.153 (-0.904, 1.210), p = 0.777), indicating no significant effect of the YDA intervention alone on self-esteem. Similarly, no significant differences in self-esteem were found between the YDA + MFG group and the control at baseline (β=-0.299 (-1.713, 1.114), p = 0.678) and 12 months (β = 0.986 (-0.495, 2.468), p = 0.192). However, at 24-months follow-ups, the YDA + MFG group showed significantly higher self-esteem than the control (β = 1.282 (0.084, 2.480), p = 0.036). Additionally, those who reported school absenteeism due to cultural or religious reasons and received the YDA + MFG intervention reported higher self-esteem than usual care (β = 1.57 (0.07, 3.07), p = 0.004). No significant moderation by menstrual hygiene knowledge or cultural attitude was detected. CONCLUSION/CONCLUSIONS:The YDA + MFG intervention and natural age progression improved self-esteem, though reliance on self-reported data may introduce bias. However, the YDA intervention alone did not significantly improve self-esteem at any assessment point.

We investigated the mediating role of alcohol use expectancies between three psychological/emotional states (depressive symptoms, hopelessness, and adverse childhood experiences (ACE)) and problematic alcohol and substance use among YLHIV in Uganda. We defined problematic substance use according to the National Institute on Drug Abuse (NIDA)-modified Alcohol, Smoking, and Substance Involvement Screening Test (NM-ASSIST) to derive a Substance Involvement (SI) score to identify participants' risk level. We grouped moderate and high risk into one category to represent 'problematic use' or use that would qualify as a substance use disorder. We tested the proposed mediation models using the PROCESS macro for mediation, moderation, and conditional process analysis version 4.1 for SPSS. We observed that higher scores for depressive symptoms, hopelessness, and ACE, were each associated with increased levels of global AUE (GAUE). However, mediation analyses revealed significant indirect effects of depressive symptoms (1.03, 95% CI 1.0002 to 1.0926), hopelessness (1.11, 95% CI 1.0172 to 1.3349), and ACE (1.08, 95% CI 1.0027 to 1.2695) on problematic substance use via GAUE. Also negative AUE (NAUE) significantly mediated the relationship between depressive symptoms, hopelessness, and ACE and problematic substance use. Our study highlights the significant role of GAUE and NAUE in mediating the relationship between ACE, depressive symptoms, hopelessness, and problematic substance use among YLHIV. The findings suggest that interventions targeting GAUE and NAUE and possibly providing effective coping mechanisms for managing depressive symptoms, hopelessness, and the impact of ACE may be crucial in reducing substance use among YLHIV.

Substance use among youth is a significant public health issue, particularly in low resource settings in Sub-Saharan Africa (SSA), where it contributes to HIV transmission and poor engagement in HIV care. This study employs machine learning (ML) techniques to develop models for predicting problematic substance use (PSU) among youth living with HIV (YLHIV) in Uganda, aiming to identify important multilevel risk factors and compare predictive performance of ML algorithms. Utilizing a cross-sectional dataset of 200 YLHIV aged 18-24 in Uganda, we trained and evaluated six predictive models, through 10-fold cross validation. Model performance was assessed using area under receiver operating characteristic curve (AUROC), and precision recall curve (AUPRC). Subsequent feature importance analysis revealed key predictors of PSU. The random forest model achieved the best discriminative performance with an AUROC of 0.78 (0.01) and AUPRC of 0.75 (0.02). Key predictors of PSU spanned individual, interpersonal, and community dimensions including depression, sexual risk-taking behaviors, monthly income, adverse childhood experiences, family involvement in selling alcohol, friends enabling access to alcohol, exposure to community educational campaigns against alcohol, household size, and knowledge of alcohol effects on HIV treatment. Our findings highlight ML's potential in predicting PSU among YLHIV and provide insights to guide targeted interventions and support policy formulations mitigating PSU effects on HIV management.

OBJECTIVES/OBJECTIVE:Achieving optimal adherence to antiretroviral therapy (ART) and viral suppression is still insufficient for attaining the UNAIDS 95-95-95 target of 2030, especially among adolescents with HIV (AWHIV). This study sought to develop a model to predict poor adherence risk among AWHIV and identify associated risk factors. DESIGN/METHODS:We utilized machine learning to predict future ART adherence among AWHIV leveraging its ability to analyze complex, multidimensional data. METHODS:We leveraged a dataset from a 6-year (2012-2018) longitudinal randomized control trial (RCT) with 635 AWHIV in Uganda. We evaluated six machine learning models and retained one with the highest area under receiver operating characteristic (AUROC), and area under precision-recall curve (AUPRC). We further identified principal factors associated with ART adherence based on the best model. RESULTS:The random forest model outperformed others, with mean AUROC: 0.71 [BC 95% confidence interval (CI) (0.69-0.72)] and AUPRC: 0.55 (BC 95% CI 0.53-0.58). The principal risk factors of poor adherence were poor adherence history; poverty; biological relationship to caregiver; self-concept; savings confidence; duration on ART; frequency discussing sensitive topics with caregivers; household size; economic group assignment; and school enrollment. CONCLUSION/CONCLUSIONS:Our findings support potential use of machine learning methods and sociobehavioral data for predicting poor ART adherence risk among AWHIV. The predictive tool can help identify AWHIV at the highest risk of treatment failure, and enable early targeted interventions. However, the tool is still preliminary and its accuracy could be improved by incorporating HIV phenotypic and clinical data. CLINICAL TRIAL NUMBER/BACKGROUND:ClinicalTrials.gov ID:NCT01790373.

This study aimed to assess HPV vaccine uptake and its predictors among adolescent girls and young women living with HIV. We analyzed cross-sectional baseline data from a pilot randomized controlled trial involving 100 girls and young women (aged 10-24 years) living with HIV and receiving care in Uganda's Greater Masaka region. The study was conducted in four Antiretroviral(ART) providing healthcare facilities between January and March 2024. Surveys were used to collect data on socio-demographics (age, religion, education), HPV acceptability, barriers to vaccination, perceived susceptibility, knowledge about HPV and cervical cancer, and HPV vaccine uptake. We then conducted a logistic regression analysis to determine the predictors of HPV vaccine uptake. We also tested assumptions for the logic regression. The health belief model guided us in selecting the variables to include in the final logistic regression model. The findings revealed a low vaccine uptake rate, with only 31% vaccinated participants. Significant predictors included sexual experience (OR = 4.08, p = 0.011) and HPV knowledge (OR = 1.41, p = 0.016). Participants without sexual experience were four times more likely to be vaccinated, and higher HPV knowledge increased the likelihood of vaccination. However, perceived barriers, susceptibility, and cervical cancer knowledge were not significant predictors. These findings highlight the need to address barriers and improve HPV knowledge to enhance vaccine uptake, particularly among adolescent girls and young women living with HIV.

Under-five mortality remains a global health issue, especially in sub-Saharan Africa, where preventable conditions largely drive the high mortality rates. Understanding the heterogeneity in utilization of reproductive, maternal, newborn, and child health services is crucial for reducing under-five mortality. Here we show that among 9307 under-five mortality cases across 31 sub-Saharan African countries (2014-2024), maternal and child health service utilization falls into three distinct patterns-lowest, medium, and highest. Socioeconomic status strongly predicts subgroup membership: higher maternal education, employment, urban residence, and wealth are associated with lower odds of being in the lowest utilization group. Inequality indices further reveal disparities by education, wealth, residence, and employment. Our findings show a strong link between socioeconomic status and maternal and child health services utilization. To address under-five mortality in sub-Saharan Africa, targeted strategies are needed to improve access and uptake of essential health services among socioeconomically disadvantaged groups.