Faculty Bibliography

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/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.

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.

Despite high prevalence of emotional and behavioral difficulties (EBDs) among adolescents living with HIV (ALHIV), there are limited randomized trials assessing the impact of interventions on these outcomes. We assessed the impact of two evidence-based interventions in a three-arm cluster randomized controlled trial (RCT) where nine clinics were randomized to one of three study arms: (1) Usual Care; (2) Group-Cognitive Behavioral Therapy (G-CBT) + Usual Care; and (3) Multiple Family groups (MFG) + Usual Care. We utilized mixed effects models to assess the effect of the intervention on EBDs. While the main effect of the intervention was not significant, χ2(2) = 0.43, p = 0.806, the main effects for time χ2(2) = 32.47, p < 0.001, and intervention-time interaction, χ2 (2) = 59.59, p < 0.001, were statistically significant, suggesting reduction in the EBDs across the groups overtime. Pairwise comparisons showed that in the G-CBT group, EBDs reduced at three months [contrast = -7.59 (CI: -8.20 - -6.99), <0.001] and 6-months [contrast = -8.11 (CI: -12.64 - -3.57), <0.001] compared to baseline. No statistically significant pairwise comparisons across time were observed in the control group, which confirmed that the significant group-by-time interactions were driven by our intervention effects. Findings that G-CBT improved EBDs in this pilot trial highlight the potential efficacy of this intervention in addressing EBDs among ALHIV. However, further studies are warranted to investigate prolonged exposure to MFG as well as combination of MFG and G-CBT to understand the nuances that will ultimately inform the development of tailored effective interventions for addressing EBDs in this vulnerable population.

One in six people are aged 10-19 years. Adolescence is a unique and formative time. Physical, emotional, and social changes, including exposure to poverty, abuse, or violence, can make adolescents vulnerable to mental health problems. Protecting adolescents from adversity, promoting socio-emotional learning and psychological well-being, and ensuring access to mental healthcare are critical for their health and well-being during adolescence and adulthood. Globally, it is estimated that 1 in 7 (14%) 10-19 year-olds experience mental health conditions (1), yet these remain largely unrecognized and untreated. Adolescents with mental health conditions are particularly vulnerable to social exclusion, discrimination, stigma (affecting readiness to seek help), educational difficulties, risk-taking behaviors, physical ill-health, and human rights violations.

We investigated how COVID-19-related disruptions influenced antiretroviral therapy (ART) adherence among young adults living with HIV (YALHIV) in Southern Uganda, a region with limited resources and high rates of HIV. Data were analyzed from 499 YALHIV aged 19 to 25, participating in the Suubi+Adherence-R2 COVID-19 Supplement study. The study measured COVID-19 disruptions using an 8-item Coronavirus Impact Scale and evaluated ART adherence through self-reported measures. Our analytical framework was informed by the Health Belief Model and generalized estimating equations were estimated. We find no statistically significant association between COVID-19 disruptions, as quantified by the COVID-19 Impact Score, and sub-optimal ART adherence (OR = 0.99, 95% CI [0.87-1.14]). However, findings revealed that being employed (OR = 1.99, 95% CI [1.07-3.71]) and older age (OR = 1.18, 95% CI [1.02-1.37]) was associated with higher likelihood of poor adherence highlighting the complex interplay between economic activity, working schedules, and health management. Other notable predictors included marital status, with cohabiting individuals showing decreased odds of poor adherence (OR = 0.25, 95% CI [0.08-0.74]) compared to single and separated YALHIV. These insights emphasize the need for multifaceted intervention strategies that consider both individual and systemic factors affecting ART adherence. Tailored interventions must address the socioeconomic challenges intensified by the pandemic and leverage the inherent resilience within this population to enhance ART adherence outcomes for YALHIV in challenging environments. Trial Registration ClinicalTrials.gov, ID: NCT01790373.

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.

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.

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.

Adolescents living with HIV (ALHIV) have low adherence to antiretroviral therapy (ART). Poverty and mental health challenges remain major drivers of this poor ART adherence. We explored the mediators of the impact of an economic empowerment intervention on ART adherence among ALHIV and assessed the moderating effects of depression. We randomized 39 clinics (702 participants) into the control or intervention groups. Participants were aged 10-16, living with HIV and taking ART. The intervention comprising matched savings account, financial literacy training, and microenterprise workshops. We fitted a sequential structural equation model to examine how the three mediators-HIV stigma, barriers to medical care, and healthcare transition readiness-influenced ART adherence at year seven. Depression was included as a moderator. At baseline, the mean age was 12 years, and only 73.0% achieved good adherence (≥ 90%). The intervention directly improved ART adherence, β = 0.060 (95% CI: 0.038, 0.081), p < 0.001. Also, there was a significant indirect effect of the intervention on ART adherence, mediated through barriers to medical care, β =  - 0.036 (95% CI: - 0.041, - 0.032), p < 0.001, and HIV stigma, β =  - 0.011 (- 0.016, - 0.007), p < 0.001. Depression reduced the effect of the intervention on ART adherence β =  - 0.114 (- 0.123, - 0.104), p < 0.001. Our results showed that providing ALHIV with financial resources improved their ART adherence; however, this was affected by depression. Therefore, programs aimed at improving outcomes in ALHIV should consider incorporating interventions that address mental health challenges in addition to poverty.