Faculty Bibliography

OBJECTIVES/OBJECTIVE:Adolescents living with HIV (ALHIV) have low viral suppression levels, with 1 in 3 ALHIV experiencing virologic failure, calling for more efforts to reverse these trends. We developed and validated a model that predicts the risk of virologic failure (VF) among ALHIV. STUDY DESIGN/METHODS:Cross-sectional study. METHODS:We used baseline data from 702 ALHIV enrolled in the Suubi + Adherence cluster-randomized clinical trial. Participants were aged 10-16 years, living with HIV and aware of their HIV status, and are living with a family. We developed a risk-prediction model for VF (viral load of ≥200 copies/mL) using sociodemographic, behavioral, psychological, economic, and treatment-related factors. LASSO logistic regression using 10-fold cross-validation with bootstrapping was used to select the predictors for the final model. Model performance was assessed by determining the discrimination using the area under the curve and calibration by drawing a calibration plot. RESULTS:Using a lambda value of 0.007, the final model had 24 predictors (and interaction terms). The predictors included the participants' age, sex, work status, stigma, depressive symptoms, adherence self-efficacy, HIV knowledge, duration with HIV, time spent on ART, communication with the caregiver, family cohesion, social support, orphanhood status, number of people in the household, HIV disclosure, years spent at the current residence, and household asset ownership. The model predicted VF with AUC of 73.8 (95 % CI: 68.3-78.0) and calibration slope of 0.985. CONCLUSIONS:We developed and validated a model to predict the risk of virologic failure among ALHIV in Uganda, demonstrating its potential utility in identifying individuals at elevated risk for VF. Future models could be refined by incorporating clinical characteristics such as CD4 count to further improve predictive accuracy.

Viral load suppression (VLS) is considered crucial in the global efforts to end the HIV/AIDS pandemic and young people lag behind adults in this important indicator. However, little is known about VLS among refugee adolescents and youth (RAY), a vulnerable group, often ignored by research, with multiple intersecting risk factors and unique challenges. The goal of this study was to determine the prevalence of VLS and examine associated risk and protective factors among RAY in refugee settlements in Uganda, a country severely affected by the HIV/AIDS pandemic and currently hosting the most refugees in sub-Saharan Africa (SSA). We analyzed cross-sectional data from a pilot cluster randomized trial with 180 participants (ages 13-30) recruited from 20 health centers in three refugee settlements between July and December 2023. We employed a hierarchical (mixed-effects) logistic regression model to examine the association between selected demographic, psychosocial, and economic factors and VLS. The prevalence of VLS among RAY was very low at just 52%. Factors associated with VLS included financial stability, adherence self-efficacy, and HIV status disclosure. Having financial savings was associated with VLS (adjusted odds ratio:2.68; 95% CI: 1.48-5.11; p = 0.003). Treatment support from others including teachers and health care providers had five-fold odds of VLS (5.0, 1.64-15.24; p = 0.005). Conversely, older age and interactions between stigma/self-efficacy and stigma/HIV status disclosure were associated with viral load non-suppression. This study highlights the urgent need for tailored interventions targeting economic and psychosocial hardships like poverty, stigma, and food insecurity to enhance HIV VLS and other treatment outcomes among RAY.

BACKGROUND:Women engaged in commercial sex work (WESW) are exposed to behavioral, biological, and structural factors that exacerbate their risk of HIV infection and other sexually transmitted infections. While commercial sex work may appear voluntary, WESW are more likely to be constrained to selling sex due to limited viable alternatives. To effectively support this vulnerable group of women, it is critical to understand factors that facilitate and impede their decisions to transition from sex work into other careers or jobs. The current study explored women's decision to transition from sex work into other careers or jobs. METHODS:Face-to-face semi-structured in-depth interviews were conducted with 53 WESW aged 20-47 enrolled within the larger Kyaterekera study, a randomized clinical trial (N = 542) implemented in 19 geographical hotspots in the Southern region of Uganda. Participants were selected based on their level of intervention attendance (high/medium/low attendance) during the 12-month follow-up (Time 2). The interviews were conducted in Luganda the widely spoken language in the study area to explore the factors influencing women's decisions to transition from sex work to other jobs or careers. The main interview question used for this study was, "What are some of the factors that may influence whether you would transition from sex work to other jobs or vocations?" All interviews were audio-recorded, transcribed verbatim, and translated into English. Thematic analysis in Dedoose software was used to analyze the data. RESULTS:Participants reported three primary types of decisions, including considering leaving sex work, deciding to leave, and staying in sex work. The emerging themes from the interviews were categorized into individual and structural level facilitators and barriers to transitioning out of sex work. Individual-level factors included issues of stigma, discrimination, and aging as factors that facilitated women's decision to leave sex work. At the interpersonal level, physical and sexual violence was noted as a reason to leave sex work. At the structural level, stigma and discrimination (from community members) were identified as facilitators to leaving sex work. Income-related factors were identified mainly as barriers to leaving sex work. CONCLUSION/CONCLUSIONS:Our study highlights the complex decision-making processes among WESW as they navigate transitions to alternative jobs or careers. By advocating for multifaceted interventions and policies tailored to the diverse challenges faced by WESW, our study contributes to a more informed approach to supporting their transition out of sex work.

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.

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.

INTRODUCTION/UNASSIGNED:, an integrated economic empowerment with relationship strengthening intervention for couples living with HIV. METHODS/UNASSIGNED:impact on (i) confidence to save, (ii) attitudes towards savings, (iii) equitable financial decision-making. RESULTS/UNASSIGNED:intervention showed significantly higher confidence to save compared to EUC (coefficient = 0.18, 95% CI: 0.05, 0.32, p < 0.001), with women having greater improvements than men (p < 0.001). However, these effects were not sustained at 15 months. No significant differences were observed between arms in attitudes towards savings. Participants in the intervention showed greater equitable financial decision-making at 10 months (coefficient = 0.13, 95%CI: 0.11, 0.25; p = 0.03) compared to EUC, with effects sustained at 15-months (coefficient = 0.21, 95% CI: 0.11, 0.32, p < 0.001). CONCLUSION/UNASSIGNED:intervention holds promise, underscoring the benefits of an integrated economic and relationship strengthening interventions among HIV-affected couples. CLINICAL TRIAL NUMBER/UNASSIGNED:NCT04906616.

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.

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.