1,721,030 research outputs found
Correlates of the use of long-acting, reversible contraceptives in women in HIV-serodiscordant relationships in Kenya and Uganda
No full textThesis (Master's)--University of Washington, 2019Background: Long-acting, reversible contraception (LARC) is highly effective; data on LARC use among women in HIV-serodiscordant partnerships are limited. Methods: Prospectively collected longitudinal data from East African women in HIV-serodiscordant partnerships were analyzed using multivariable generalized estimating equations to assess correlates of LARC use. Results: Nine percent (9%) of 679 HIV-positive and 13% of 328 HIV-negative women used LARC at enrollment, and 27% and 20% used LARC at any point, respectively. Correlates of LARC use during follow up included LARC use at baseline, being Kenyan, having condomless sex, and having children already (p<0.05). Conclusion: Women using LARC are most likely to continue LARC use and their experiences are important to share widely as a means of encouraging LARC use among their peers
SEXUAL BEHAVIOUR AND HIV RISK AMONG YOUNG WOMEN USING PrEP IN KENYA
No full textThesis (Master's)--University of Washington, 2021Introduction Adolescent girls and young women (AGYW) in sub-Saharan Africa are disproportionately affected by HIV. In 2020, UNAIDS estimated that AGYW contributed 30% of all new HIV infections in sub-Saharan Africa and were 2.5 times more likely to acquire HIV than young men of the same age1. PrEP is an effective HIV prevention tool available to them. However, multiple studies report that PrEP use in this age group is not sustained after initiation. If AGYW maintain sexual activity and multiple partners after discontinuing PrEP, they return to having potential risk for acquiring HIV. Questions remain about whether AGYW maintain a consistent level of sexual activity and HIV risk if this risk can be assessed using validated scoring tools, including the VOICE risk score. Method: Between 2016 and 2018, 350 young women aged 18-24 years with high risk of HIV were enrolled into the monitoring PrEP among young adult women (MPYA) study in Kisumu and Thika, Kenya and followed for up-to 24 months. Participants were offered PrEP, provided adherence support through reminder short message service (SMS), and monitored for PrEP adherence via electronic pill boxes. Data on adherence, sexual risk behavior and risk perceptions were collected during quarterly study visits. We used generalized estimating equations to estimate whether the number of sexual partnerships, condomless sex acts, and self-assessed risk perception were associated with the level of HIV risk score.
Results: At baseline, the median age was 21 years, majority reported high school. Completion, 55% were single but had a stable partner, majority being students (38.9%). When comparing those who had a high (≥6) versus a moderate risk score(4,5), The likelihood of having a high risk score was greater among AGYW with more partners (odds ratio [OR] 2.2,95% CI 1.6, 3.1) and those who reported ≥1 casual partners (OR 2.2, 95% CI: 1.6, 3.1) but neither were statistically significant different after adjustment for confounding factors. The likelihood of reporting any condomless sex was similar in both groups with an OR of 1.0 (95% CI 0.7, 1.4). When adjusted for confounding, the difference was statistically significant with an adjusted OR of 1.3 (95% CI: 1.1, 2.5). There was a reduction in self-assessed perception of being at risk of HIV, from 52% at enrolment to 12% at month 24 feeling at risk. There was no association between the score and self-assessed risk perception.
Conclusion: In our study we found that sexual risk behavior was similar among those with moderate or high risk on the VOICE scoring tool. We need to identify risk scoring tools that capture HIV sexual risk and the varying levels of risk to support appropriate, client-tailored counseling about HIV and HIV prevention options for AGYW
Improving Pre-exposure Prophylaxis (PrEP) delivery for HIV prevention among women of reproductive age in Sub-Saharan Africa
No full textThesis (Ph.D.)--University of Washington, 2024Adolescent girls and young women in East and Southern Africa are disproportionately affected by HIV. Tenofovir disoproxil fumarate (TDF)-based oral pre-exposure prophylaxis (PrEP) reduces the risk of HIV acquisition with consistent daily adherence and has been recommended for use since 2015 by the World Health Organization. However, for a multitude of reasons, young African women have difficulty adhering to daily pill-taking and/or accessing refills for oral PrEP. TDF-based oral PrEP is generally safe but has been linked with low levels of bone mineral density (BMD) loss. Research is needed to evaluate if the use of TDF-based oral PrEP during pregnancy exacerbates maternal bone mineral density loss. Further, drug level monitoring (accompanied by feedback) and data-driven adherence counseling are essential to supporting young women using PrEP. Novel tools such as point-of-care tenofovir (POC TFV) urine test may have a significant impact on improving PrEP adherence. In addition to research to optimize the use of daily oral PrEP, new products with longer-acting formulations have been proven efficacious and are nearing programmatic implementation. These products, including an injection and a vaginal ring, have the potential to overcome the challenges of daily adherence and curtail the high HIV burden among African women. By leveraging data from recent prospective cohort studies, we aimed to contribute to global efforts to optimize PrEP delivery to young women through this dissertation.Our first study leveraged data from women enrolled in a prospective cohort study evaluating the impact of concurrent TDF-based PrEP and DMPA on bone health in Kampala, Uganda. In a sub-study of women who became pregnant in that cohort, we evaluated the impact of TDF-based PrEP use on BMD loss during pregnancy. Secondarily, we investigated the effect of pregnancy on daily oral PrEP adherence and continuation. We observed significant BMD loss among pregnant women who were using PrEP, which was likely driven by pregnancy, rather than PrEP use. Our study also reported that women experiencing pregnancy were significantly less likely to use PrEP than women without a pregnancy through analyses comparing pregnant versus non-pregnant women and pregnant versus non-pregnant periods among women who become pregnant.
Our second study evaluates a recently developed and validated point-of-care urine tenofovir (POC TFV) test to determine whether its use improves the accuracy of self-reported adherence to pre-exposure prophylaxis (PrEP) and sexual behavior. We leveraged data from a prospective cohort of young women using TDF-based oral PrEP in Uganda. We observed that the introduction of a POC urine test for TFV substantially improved the accuracy of self-reported PrEP adherence. We also saw a moderate concordance between the POC urine TFV and TFV-DP in DBS, and greater reports of activities that are traditionally challenging to disclose to an HIV prevention counselor – condomless sex and low PrEP adherence – when the POC urine test was used. Further research is needed to evaluate the utility of POC urine TFV testing to monitor PrEP adherence and inform provider decision-making in clinic settings. However, our findings indicate that the POC urine TFV test could play an important role in PrEP adherence counseling, particularly in a low-resource setting, since it is projected to be low-cost once available commercially.
Our third study evaluated preferences and willingness to use novel PrEP products (i.e., injectable cabotegravir and dapivirine vaginal ring) among oral PrEP-experienced and inexperienced Kenyan women accessing family planning clinics. We conducted a cross-sectional study among women seeking services at 12 family planning clinics. We found that an overwhelming number of participants preferred injectable PrEP and would like to switch from their current oral PrEP regimen to injectable PrEP if it were available to them. Among participants without prior PrEP experience, 74% preferred injectable PrEP, 19% preferred oral PrEP, and 4% preferred the vaginal ring. Among previous oral PrEP users, 82% preferred injectable PrEP, 16% preferred oral PrEP, and only 2% preferred the dapivirine vaginal ring. Our findings suggest that in this population of reproductive-age women in Kenya, adding injectable PrEP to the HIV prevention toolkit could potentially increase PrEP use and overall coverage of HIV prevention.
Together, the results presented in this dissertation provide insights that have the potential to impact the delivery of daily oral PrEP and plans for the delivery of novel PrEP products to young women in Eastern and Southern Africa. The findings of these studies will inform strategies to support PrEP adherence and continuation among women during pregnancy and the postpartum period, provide novel data on the use of POC TFV testing to support adherence counseling, and inform decisions on novel PrEP product provision for young African women. As newer PrEP products are nearing large-scale implementation, there is a need for making pregnant and adolescent girls, as well as young women, a priority population for these prevention methods, and committing to making these methods available, accessible, and affordable
Contraceptive Decision-Making and Use Among Latina Adolescents Aged 18-19 in the United States
No full textThesis (Ph.D.)--University of Washington, 2022Contraceptives offer individuals who do not want to become pregnant one form of reproductive autonomy. They are safe and effective when used correctly, and in the case of long-acting reversible contraception (LARC), are associated with very low failure rates, user independence, and convenience. For adolescents, who are beginning to engage in sexual activity, and are also likely to want to prevent pregnancy, contraceptives provide a mechanism to do so. In the United States, where the adolescent birth rate is still significantly higher than other industrialized nations, there is particular interest by policymakers and reproductive health program developers to better understand how, when, and why adolescents use contraceptives. However, U.S. history is fraught with coercive, racist, and discriminatory practices and policies targeted at marginalized groups, and this has long-lasting ramifications on individuals’ contraceptive use perceptions and behaviors. Nationally representative, cross-sectional survey data, from sources such as the National Survey of Family Growth and the Youth Risk Behavior Surveillance System, provide an initial assessment of U.S. adolescent contraceptive use. Data from these surveys indicate that U.S. Hispanic adolescents are less likely to use effective contraception than their non-Hispanic white counterparts. Furthermore, they experience disproportionately higher rates of unintended pregnancy. However, beyond these data, very little is known about U.S. Latina adolescent contraceptive use patterns and decision-making. This dissertation aims to address this gap by: 1) investigating Latina adolescents’ consistency in non-barrier contraceptive method use and factors associated with method non-use, switching, and consistency; 2) assessing whether Latina adolescents using different types of non-barrier contraceptive methods, specifically LARC (implants and intrauterine devices), are more likely to engage in condomless sex and less likely to use dual methods of protection (combined use of non-barrier contraception and condoms); and 3) explore the influential factors that may interact in the Latina adolescent’s decision-making process around contraception use. Previous research has indicated that U.S. Latinas of any age are less likely to use contraception, may have different method preferences, and may be inclined to earlier discontinuation, but we are unaware of any longitudinal investigation of Latina adolescent contraceptive use. Our research fills this gap by exploring the temporal dynamics of and factors associated with Latina adolescent contraceptive use over a nine-month period within a cohort of individuals who were trying to avoid pregnancy. We found that those using intrauterine devices (IUD) were most likely to be consistently using the same method nine months later than users of other non-barrier methods, and factors associated with this included being older, having never been pregnant, having higher contraceptive knowledge, and having a greater perceived risk of pregnancy. This suggests that the IUD may offer greater contraceptive stability for Latina adolescents who do not want to become pregnant. While non-barrier contraception may offer protection from unintended pregnancy, contemporary literature among women of any reproductive age and predominantly non-Latina white adolescents has reported that users of specific contraceptive methods, notably LARC, appear less likely to use dual protection (combined use of non-barrier contraception and condoms) than those using short-acting hormonal methods. However, there is also some conflicting research indicating that LARC use may not lead to diminished perceptions of STI risk or actual condom use. Alongside this, there has been a recent notable rise in sexually transmitted infections (STIs) among U.S. adolescents, with Latina adolescents experiencing STI rates up to three times greater than their non-Latina white counterparts. The higher STI rates, mixed findings on this topic, and data indicating that Latina adolescents use contraceptives and condoms differently than their counterparts in other racial and ethnic groups, highlight important questions to ask about Latinas’ use of dual protection. Our research found that Latina adolescents using any type of non-barrier contraception had higher rates of recent condomless sex than non-users, and that among those using non-barrier contraception, LARC or injection users had significantly lower rates of dual protection use. Taken together, this suggests that Latina adolescents using non-barrier contraception, particularly LARC, may be at greater risk for STIs (although, this needs to be investigated in future research) and emphasizes the importance of including information on dual protection in contraceptive counseling and reproductive health interventions. Qualitative research methods provide us with an opportunity to gain deeper insight and a more nuanced understanding of factors that may influence Latina adolescents’ contraceptive choices. We leveraged interview data collected from 37 Latina adolescents to explore how interpersonal- and individual-level factors may interact in the contraceptive decision-making process. Our analysis sheds light on the interconnected roles that future ambitions, partner influence, pregnancy intentions, method consistency, fear, and expected familial responses to pregnancy play in this process. The collective findings in this dissertation offer enhanced knowledge on how, when, and why U.S. Latina adolescents use non-barrier contraception, which can be pragmatically applied in patient-centered contraceptive counseling and reproductive health programs. This work aims to motivate recognition of the potentially differential contraceptive use behaviors and priorities of U.S. Latina adolescents and highlight the need for reproductive justice-informed approaches that are more responsive and attentive to their individual needs and desires
Safer Conception Among HIV-1 Sero-Discordant Couples in East Africa: Understanding Knowledge, Attitudes, and Experiences
Full text linkThesis (Master's)--University of Washington, 2016-06Context: Supporting people affected by HIV-1 in achieving their reproductive goals while minimizing the risk of HIV-1 transmission is a public health imperative. Background: For HIV-1 serodiscordant couples, HIV-1 exposure and risk of transmission to the uninfected partner and unborn children is heightened during pregnancy attempts but safer conception strategies can mitigate risk. Understanding couples’ choices and experiences with safer conception can be useful for programmatic recommendations as safer conception programs are scaled up. Methods: 1013 high-risk, heterosexual HIV-1 serodiscordant couples from Kenya and Uganda were followed for two years in an open-label delivery study of integrated pre-exposure prophylaxis (PrEP) and antiretroviral therapy (ART), the Partners Demonstration Project. Annually, we assessed participant experience with safer conception strategies. Multivariate logistic regression was used to characterize women who reported ever having used a safer conception strategy during their first annual visit. Results: 859 couples were included in analysis. 66% of couples had HIV-infected women and 86% desired future children. The median age for women was 27 (interquartile range: 23-32). At the first annual visit, 32% of women reported use of a safer conception strategy ever in their life: 14% reported using ART, 16% PrEP, 3% self-insemination, and 2% STI treatment. Women who reported discussing their fertility desires with their male partners (adjusted odds ratio (aOR) = 1.91, 95% confidence interval (CI) 1.26-2.589), had no living children at the time of study enrollment (aOR = 1.71, 95% CI 1.14-2.57), and were HIV-uninfected (aOR = 1.56, 95% CI 1.11-2.20) were more likely to report having used at least one safer conception strategy. Conclusions: HIV-1 prevention counseling for serodiscordant couples should integrate opportunities for couples to share their fertility desires and discuss preferences for safer conception strategies
Optimizing the integration of gender-based violence screening and referral in HIV care settings
No full textThesis (Ph.D.)--University of Washington, 2023Uganda faces a disproportionate burden of syndemic HIV and gender-based violence (GBV). There are national guidelines calling for implementation of strategies that concurrently address challenges of GBV and HIV (i.e., via GBV identification and referral for clients in HIV care settings); however, there is limited evidence outlining the extent to which this guidance is presently implemented in HIV care settings in Uganda. We aimed to generate evidence facilitating the transition from tested approaches to evidence-based interventions that concurrently address the GBV and HIV syndemic. Our first study leveraged secondary data from a cohort of serodifferent couples in Uganda to assess the relationship between intimate partner violence (IPV) exposure and PrEP or ART adherence among both members of the couple. Secondarily, we assessed the relationship between perceived relationship powerlessness and PrEP or ART adherence. We observed that, among partners living with HIV, recent IPV exposure was associated with lower ART adherence compared to those without recent IPV exposure. We did not observe this association for HIV-negative partners. Among HIV-negative partners, we found that those reporting low perceived relationship powerlessness were more likely to be PrEP adherent. We did not observe this association for partners living with HIV. Our second evaluation leveraged a mixed methods approach to assess providers’ implementation of GBV screening and referral in public ART clinics in Uganda. This assessment was guided by the Reach, Effectiveness, Adoption, Implementation and Maintenance implementation evaluation framework. We found that most providers were trained to administer GBV screening to clients in ART clinics. Additionally, we found that screening supported the identification of GBV among ART clinic clients. In qualitative in-depth interviews with ART clinic providers and referral partners, socio-cultural norms and financial constraints were identified as threats to supporting clients who were struggling with interpersonal violence. Interview respondents recommended financial support to facilitate referrals and joint meetings to reinforce the referral network as potential strategies to address key threats to successfully support GBV-expose ART clinic clients. In our third evaluation we qualitatively assessed barriers and facilitators to providers offering GBV screening and referral to clients in ART clinics. This analysis was informed by the Theoretical Domains Implementation Science determinants framework. Our results from this evaluation revealed that socio-cultural factors (e.g., harmful gender norms and fear of judgment associated with being a GBV survivor) negatively influenced the provision of GBV screening and referral to clients seeking care in ART clinics. Providers’ negative expectations about referral partners’ ability to provide meaningful support to clients, financial burden associated with pursuing referral services and ineffective referral networks were also identified as barriers to referral
HIV-1 Risk and Prevention Strategies for Women during Pregnancy and Postpartum
Full text linkThesis (Ph.D.)--University of Washington, 2017-12HIV-1 is the leading cause of death worldwide among women of reproductive age, and this group is a priority to reach with effective HIV-1 prevention. There is great potential to provide HIV-1 interventions to women during the periconception, pregnancy, and postpartum periods by leveraging existing healthcare settings that serve women and couples at high risk of HIV-1 acquisition. These opportunities include integration of HIV-1 prevention strategies within antenatal and postnatal care programs in settings with high HIV-1 prevalence and inclusion of safer conception programs within clinical HIV-1 care for HIV-1 affected individuals and couples desiring children. Specifically, antiretrovirals, as PrEP used by HIV-1 uninfected people and ART used by HIV-1 infected people, are highly effective and important for women and couples, especially those planning and experiencing pregnancy. The aims within this dissertation address questions regarding HIV-1 risk and implementation of antiretrovirals for HIV-1 prevention among women and their partners during reproductive stages, including: quantifying the risk of female HIV-1 acquisition in different reproductive stages, making the case for PrEP as a highly efficacious HIV-1 strategy for women, and describing fertility intentions and willingness to use safer conception strategies during pregnancy attempts among HIV-1 infected individuals. Previous studies have shown that pregnancy and postpartum are periods with heightened HIV-1 acquisition risk for women, but it is not clear whether this is primarily driven by biological or behavioral factors. We have addressed this gap by using robust data from two longitudinal studies to estimate the per coital act probability of female HIV-1 acquisition during the early pregnancy, late pregnancy, and postpartum stages, relative to time periods to unrelated to pregnancy. We found that the risk of HIV-1 transmission per coital act steadily increased pregnancy and was highest during postpartum, even after accounting for sexual behavior, PrEP, and HIV-1 viral load, suggesting that biological changes during these periods increase HIV-1 risk. Conflicting results and conclusions from the initial randomized clinical trials that assessed efficacy of PrEP for HIV-1 prevention among women has spurred debate about whether PrEP is a strategy that women will use effectively. This debate has delayed the initiation of programs to deliver PrEP to women, and specifically has been a barrier to the integration of PrEP into antenatal and postnatal care where it has the potential to reach women who most need enhanced HIV-1 prevention. We have objectively assessed and synthesized existing evidence of PrEP efficacy among women and made a conclusive case that PrEP is an effective HIV-1 prevention strategy for women. Couples affected by HIV-1 with fertility desires experience heightened vulnerability to HIV-1 acquisition when they forgo condom use during pregnancy attempts. “Safer conception” is a risk reduction approach where HIV-1 serodiscordant couples use one or more strategies to reduce the risk of HIV-1 transmission and optimize fertility during pregnancy attempts. We have contributed to the growing demand for information on safer conception with a cross-sectional study to describe fertility intentions and preferences for safer conception strategies, including PrEP and ART, among HIV-1 infected individuals in Seattle, WA. The collective results from this dissertation provide evidence for the urgent need to enhance HIV-1 prevention during pregnancy and the postpartum period, and advance global and local delivery mechanisms for PrEP and ART during periods of heightened risk when they can have substantial HIV-1 prevention impact
The impact of mental health on unintended pregnancies within HIV serodiscordant heterosexual couples in Uganda and Kenya
No full textThesis (Master's)--University of Washington, 2019Background. Depression among women has important sequelae prior to, during, and after pregnancy. Minimal research has explored the impact of depression on pregnancy incidence. Methods. We used data from the Partners Demonstration Project, an evaluation of integrated PrEP and ART delivery to 1,013 HIV serodiscordant couples in Kenya and Uganda. We administered socio-behavioral questionnaires, including assessment of fertility intentions, “probable depression”, “hazardous” alcohol use, and stigma internalized and perceived, at enrollment and annually for up to 2 years. We used Cox proportional hazards models to assess the association of mental health and incident pregnancy, including separate models for the incidence of unintended pregnancy. Results. Of 1,013 women, 67.0% were living with HIV, 94.6% were married to their study partner, and 56.4% had no children at enrollment. Nearly 20.0% had probable depression at some point during the study and “probable depression” was reported at 9.0% of women’s study visits. We observed 238 incident pregnancies, 29.8% of which were unintended. “Probable depression” was associated with an increased rate of intended (adjusted HR=1.62, 95% CI: 1.12-2.36) and unintended pregnancy (adjusted HR=1.48, 95% CI: 0.73-2.98). Stigma and “hazardous” alcohol use were not associated with pregnancy incidence (adjusted HR=1.15, 95% CI: 0.89-1.49), (adjusted HR=0.81, 95% CI: 0.54-1.21) Conclusions. Women with probable depression were more likely to experience pregnancy. These findings highlight the importance of integrating mental health screening and care into sexual and reproductive health settings in order to reach women who may be experiencing untreated depressive symptoms. Key words: Depression, pregnancy, unintended pregnancy, women, Afric
Partner violence and self-reported pre-exposure prophylaxis (PrEP) interruptions among HIV negative partners in HIV serodiscordant couples in Kenya and Uganda.
No full textThesis (Master's)--University of Washington, 2017-06Abstract: Background: Pre-exposure prophylaxis (PrEP) is effective for HIV prevention among diverse populations and studies of PrEP delivery are investigating ways to deliver PrEP with high adherence. In many settings with high HIV burden, where PrEP is an important intervention, intimate partner violence (IPV) is reported often. We examined the role of IPV to influence interruptions in PrEP use. Methods: We analyzed data from 1,013 serodiscordant heterosexual couples enrolled in a large PrEP demonstration project in Kenya and Uganda, the Partners Demonstration Project. At quarterly study visits, HIV negative participants receiving PrEP self-reported interruptions in their PrEP use and experiences with IPV. The association of IPV and PrEP interruptions was analyzed using multivariate generalized estimating equations. Results: Of 1,013 HIV negative people who used PrEP during the study, 67% were male and the median age was 30 (interquartile range [IQR] 26-36). Interruptions in PrEP use were reported at 328 visits (7.1% of all visits). The median length of PrEP interruption was 28 days (interquartile range [IQR]: 7-45). At baseline and follow up there were 53 reports of abuse by HIV negative partners, including physical, economic, verbal, or other types of abuse. The frequency of PrEP interruption among people who experienced IPV was 23.8% and those without IPV was 6.9%. The crude odds ratio for PrEP interruption was 3.83 (95% CI 1.8-8.0) and remained significant after adjustment for age, and frequency of intercourse (aOR=2.64, 95% CI 1.17-6.00). Conclusion: IPV was more likely to be reported at visits when PrEP interruptions were also reported, which may have implications for successful adherence to PrEP. Within PrEP delivery, there may be opportunities to assess and intervene on IPV in order to bolster adherence
Depression and HIV Pre-Exposure Prophylaxis Use among sub-Saharan African Women
No full textThesis (Ph.D.)--University of Washington, 2019Daily, 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
- …
