ABSTRACT
Introduction: Stress is associated with multiple adverse health outcomes, including hypertension. The impact of stress on health may be moderated by social support. The distribution of stress, support, and their association with hypertension have not been well described in low-income countries that face severe poverty. Over the past decade, Haiti has suffered massive natural disasters including the 2010 earthquake, cholera outbreak, COVID-19 pandemic, and recurrent civil instability-all of which may act as prolonged stressors.Hypothesis: We assessed the hypotheses that 1) there are high levels of both stress and support in Haiti, and 2) high support would moderate the relationship between high stress and hypertension. Method(s): We measured stress and social support using validated instruments in a population-representative cohort of adults living in urban Port-au-Prince, Haiti between March 2019 and April 2021. Stress was measured using the Perceived Stress Scale, while social support was measured using the Multidimensional Scale of Perceived Social Support. For visualization, continuous scores were categorized using equal-width groups (stress: low (1-5), moderate (6-10), high (11-16);support: low (7-21), low-moderate (22-35), moderate (36-49), moderate-high (50-64), high (65-77)). Linear regression models were used to quantify the associations between: 1) stress and support adjusting for age and sex, 2) blood pressure and stress adjusting for age and sex. A formal moderation analysis was conducted to assess if support moderated the relationship between stress and blood pressure. Result(s): Among 2,817 adults, 59.7% female and the median age was 40 years (IQR 28-55). The majority had an income of less than 1 US dollar a day (69.7%). The median stress score was 8 out of 16 points, and median support score was 61 out of 77 points. Stress was higher with older ages (60+ years versus 18-29 years: +0.79 points, 95% CI 0.51 to 1.08) and in females (+0.85 points, 95% CI +0.65 to +1.06). Support was higher in males (+3.29 points, 95% CI 2.19 to 4.39). Support was inversely associated with stress, adjusting for age and sex (-0.04 points, 95% CI -0.04 to -0.03). Stress was not associated with systolic or diastolic blood pressure after adjustment for age and sex. Support did not moderate the association between stress and blood pressure. Conclusion(s): In this urban cohort of Haitian adults living with chronic civil instability, stress was moderate and support was high. While support was associated with lower stress, it did not moderate the relationship between stress and blood pressure. Despite the high levels of instability in Haiti, participants displayed resiliency through high levels of support, which may be an underutilized resource in reducing stress and long-term negative health outcomes.
ABSTRACT
Background: Delays in ART initiation for TB testing are associated with high rates of loss to follow-up. There are limited data on outcomes with same-day testing and treatment for patients with TB symptoms at HIV diagnosis. Methods: We conducted a randomized trial comparing same-day and rapid (7 days) TB testing and treatment initiation among adult patients with TB symptoms at HIV diagnosis at GHESKIO in Haiti. The same-day group received Xpert Ultra results and initiated either TB medication or ART on the day of HIV diagnosis. The rapid group received Ultra results within the first week and started ART on Day 7 if not diagnosed with TB. Dolutegravir (DTG) replaced efavirenz (EFV) as the first-line anchor drug in December 2018. The primary outcome was 48-week HIV-1 RNA <200 copies/mL. Results: Between November 2017 and December 2019, 500 participants were randomized to rapid (n=250) or same-day treatment (n=250) (Table 1). 234 (46.8%) were female, median age was 37 (IQR: 30, 45), and median CD4 count was 278 (134, 421). In the rapid group, 40/41 (97.6%) participants diagnosed with TB started TB drugs;244 (97.6%) started ART. In the same-day group, 45/45 (100%) diagnosed with TB started TB drugs;250 (99.6%) started ART. There were no statistically significant differences in 48-week outcomes between groups. In the rapid group, 224/250 (89.6%) were retained in care, and of these, 171 (76.3%) had HIV-1 RNA <200 copies/mL. In the same-day group, 219/250 (87.6%) were retained in care, and of these, 155 (70.8%) had HIV-1 RNA <200 copies/mL. The primary outcome (48-week HIV-1 RNA <200 copies/mL) was achieved by 171/250 (68.4%) in the rapid group and 155/250 (62.0%) in the same-day group (p=0.133). Outcomes were superior among participants who initiated ART with DTG instead of EFV, with HIV-1 RNA <200 copies/mL in 82.4% vs. 68.1%, respectively, (p=0.001) among those receiving viral load testing, and 75.3% vs. 60.4% among those randomized (p<0.001). Conclusion: Among patients with TB symptoms at HIV diagnosis, both rapid and same-day treatment are associated with near-universal initiation of TB treatment and ART, with no significant difference in 48-week outcomes. Viral suppression rates were lower than anticipated, which we attribute to high rates of transmitted EFV resistance, political instability with a national lockdown, and the SARS-CoV-2 outbreak in Haiti during the study period. Viral suppression rates are superior with DTG, supporting the rapid transition from EFV to DTGbased ART.