Intimate partner violence and HIV treatment adherence in urban South Africa: Mediating role of perinatal common mental disorders.

Background: Antiretroviral therapy (ART) has potential to eliminate perinatal HIV infections, but adherence to ART in late pregnancy and postpartum is often suboptimal. Intimate partner violence (IPV) may influence non-adherence among perinatal women living with HIV (WWH), but few quantitative studies have examined this over time or explored mechanisms for this association. Methods: We used secondary data from a parent trial in Johannesburg comprising WWH from the control arm (n=63) and WWH ineligible for the trial (n=133). Trained nurse researchers administered questionnaires at first antenatal visit on past-year psychological, physical, and/or sexual IPV (WHO instrument), socio-demographics (age, food security, education), and perinatal common mental symptoms of depression (Hospital Anxiety and Depression Screener-d); anxiety (HADS-a); post-traumatic stress disorder (PTSD; Harvard Trauma Questionnaire). At endline visit 2-4 months postpartum, nurse researchers assessed self-reported ART adherence using a visual analog scale (with ≥95% considered "good"). We fitted structural equation models (SEM) in MPlus to explore direct and indirect effects of IPV on ART adherence. Results: Of 196 perinatal WWH, 53.1% reported IPV exposure at baseline. The majority of participants (85.7%) had good perinatal ART adherence. In adjusted models, IPV at baseline was associated with halved odds of good adherence (aOR=0.51, 95%CI=0.20-0.96). IPV was associated with higher adjusted odds of probable depression (aOR=4.64), anxiety (aOR=2.85), and PTSD (aOR=3.42). In SEM, IPV had a direct (standardized coef=-0.22) and indirect effect (coef=-0.05) on ART via common mental disorders. The total effect of IPV on perinatal adherence was of moderate size (coef= -0.27) and the model had good fit (CFI=0.972; TLI=0.969; RMSEA=0.045; SRMR=0.076). Conclusion: IPV was longitudinally associated with perinatal ART non-adherence in part due to its relationship with mental health symptomology. Addressing IPV within clinical care has potential to improve perinatal mental health, maternal HIV outcomes, and HIV-free infant survival.

Mechanisms linking intimate partner violence and prevention of mother-to-child transmission of HIV: A qualitative study in South Africa.

Prevention of mother-to-child transmission (PMTCT) can virtually eliminate HIV infection among infants, yet up to one-third of women miss PMTCT steps. Little is known about how partner dynamics such as intimate partner violence (IPV) influence pregnant and postpartum women's adherence to PMTCT. We conducted 32 qualitative interviews with HIV-positive pregnant and postpartum women in Johannesburg who experienced IPV. Trained researchers conducted in-depth interviews over the period of May 2014-Nov 2015 using narrative and social constructionist approaches. Interviews were transcribed verbatim and analyzed thematically and inductively using Dedoose qualitative software. Twenty-six women experienced recent IPV and one-third had poor adherence to PMTCT. Women's experience of partner violence influenced PMTCT behaviors through four pathways. First, fear of partner disclosure led some women to hide their HIV status to avoid a violent reaction. Despite strategic non-disclosure, several maintained good adherence by hiding medication or moving out from their partner's home. Second, IPV caused feelings of depression and anxiety that led to intentionally or accidentally missing medication. Five women stopped treatment altogether, in a type of passive suicidality, hoping to end the distress of IPV. Third, men's controlling behaviors reduced access to friends and family, limiting social support needed for good adherence. Fourth, in a protective pathway, women reported good adherence partly due to their mothering role. The identity around motherhood was used as a coping technique, reminding women that their infant's wellbeing depended on their own health. PMTCT is essential to prevent vertical HIV transmission, but women living with IPV face multiple pathways to non-adherence. Addressing IPV in antenatal care can support the health of women and infants and may enhance PMTCT coverage.

HIV testing in the critical care setting: views of patients, family members and health providers from urban South Africa.

As antiretroviral treatment has led to decreased morbidity, HIV testing policy has increasingly shifted towards routine, provider-initiated approaches. Yet, few studies have examined the acceptability of provider-initiated HIV testing in the intensive, or critical care setting, where knowledge of HIV status is likely to impact on clinical management but explicit consent for testing is difficult to obtain. We conducted qualitative research in an urban hospital and clinic in Johannesburg. In-depth interviews were conducted among HIV testing clients (n = 20), recently discharged critical care patients (n = 13) and family members of critical care patients (n = 14). One focus group discussion was held with health care providers (n = 10). HIV testing in critical care was viewed as acceptable but challenging to implement. An overarching theme of ambivalence emerged from patients and families, who saw HIV testing as a pre-requisite to appropriate clinical care, but were concerned about the quality of its delivery. While providers were aware of the current "no testing without consent" policy, they expressed frustration in cases when testing was in the patient's best interest but consent could not be obtained. Furthermore, providers found it stressful to weigh up patient confidentiality against medical necessity when assessing patients' "best interests". Without specific guidelines, they often developed pragmatic, ad hoc ways to resolve dilemmas around testing in critical care. Our findings suggest that HIV testing guidelines specific to the critical care setting may help providers do their jobs more ethically and transparently. Provider-initiated approaches are likely to be acceptable to patients and may improve clinical outcomes, but training and support in policy implementation and ethical decision-making are essential.

Do evolutionary constraints on thermal performance manifest at different organizational scales?

The two foremost hypotheses on the evolutionary constraints on an organism's thermal sensitivity­the hotter-is-better expectation, and the specialist-generalist trade-off­have received mixed support from empirical studies testing for their existence. Could these conflicting results reflect confusion regarding the organizational level (i.e. species > population > individual) at which these constraints should manifest? We propose that these evolutionary constraints should manifest at different organizational levels because of differences in their underlying causes and requirements. The hotter-is-better expectation should only manifest across separate evolutionary units (e.g. species, populations), and not within populations. The specialist-generalist trade-off, by contrast, should manifest within as well as between separate evolutionary units. We measured the thermal sensitivity of sprint performance for 440 rainforest sun skinks (Lampropholis coggeri) representing 10 populations, and used the resulting performance curves to test for evidence for the hypothesized constraints at two organizational levels: (i) across populations and (ii) within populations. As predicted, the hotter-is-better expectation was evident only at the across-population level, whereas the specialist-generalist trade-off was evident within, as well as across, populations. Our results suggest that, depending on the processes that drive them, evolutionary constraints can manifest at different organizational levels. Consideration of these underlying processes, and the organizational level at which a constraint should manifest, may help resolve conflicting empirical results.

Susceptibility to ischemia-induced ventricular fibrillation in isolated female rat hearts varies moderately with estrous cycle stage.

INTRODUCTION: The vast majority of studies employing the isolated perfused rat heart model to study ischemic arrhythmias have used male rats only. The objective of this study was to determine the susceptibility to ischemia-induced ventricular fibrillation (VF) in isolated female rat hearts in each stage of the estrous cycle that corresponds with a different endogenous reproductive hormonal environment. METHODS: Hearts were isolated from female rats under pentobarbital anesthesia and perfused with modified Krebs solution containing 3mM K(+). Experiments were grouped according to estrous cycle stage that was determined by prior vaginal lavage (n=10-13 per group). A group of male rat hearts was used as the control. Regional ischemia was induced by coronary ligation and maintained for 30min. The incidence of VF was determined from the ECG. RESULTS: The incidence of VF in male hearts was 100%, while the incidence of VF in female hearts was also high but varied moderately with stage of the estrous cycle (diestrus 70%, metestrus 100%, proestrus 90%, estrus 69%; P>0.05). Compared to male hearts, the onset of VF was similar in all groups except for hearts excised from rats in proestrus, in which it was delayed. There was no difference between groups in an arrhythmia score, ischemic zone size, or baseline electrocardiographic or hemodynamic variables. DISCUSSION: In conclusion, the susceptibility of isolated female rat hearts to ischemic VF is comparable to that of male rat hearts, meaning that isolated female rat hearts can be used as controls in studies to assess antiarrhythmic drug efficacy. Since female rats can be used for isolated heart studies of ischemic VF, the need to cull female rats is reduced. However, the variation in VF susceptibility in female rat hearts that is associated with the different stages of the estrous cycle may affect statistical power that could potentially lead to Type II statistical errors. This problem can be prevented with careful randomization.

Reduced antiarrhythmic efficacy of verapamil in isolated rat hearts in the presence of elevated extracellular calcium.

An isolated heart method that has been proposed to aid in ascertaining the involvement of L-type calcium channel blockade in the mechanism of action of novel antiarrhythmic drugs involves increasing the calcium concentration in the perfusion buffer. The purpose of this study was to determine the validity of this method using an established L-type calcium channel blocker, verapamil. Isolated rat hearts were perfused with normal calcium (1.4 mM) Krebs solution containing drug vehicle only, a normal calcium solution containing verapamil (300 nM), or a high calcium (2.8 mM) solution containing verapamil. The occurrence of ventricular fibrillation during a subsequent period of regional myocardial ischemia was monitored. The incidence of ventricular fibrillation was significantly reduced from 80% in controls to 20% by perfusion with verapamil in normal calcium Krebs solution (P < 0.05). Perfusion with the high calcium solution increased the incidence of ventricular fibrillation in the presence of verapamil to 40% (P > 0.05 versus controls). We conclude that the antiarrhythmic effect of verapamil in isolated hearts can be attenuated by increasing the calcium content of the perfusion solution, but a twofold increase in the calcium concentration failed to fully restore susceptibility to ventricular fibrillation to that observed in verapamil-free controls.

Mitochondrial uncoupling agents trigger ventricular fibrillation in isolated rat hearts.

Sudden cardiac death resulting from ventricular fibrillation (VF) remains a major cause of mortality. The purpose of this study was to investigate the roles of loss of oxidative phosphorylation and activation of the mitochondrial ATP-sensitive K+ channel and permeability transition pore in VF development during myocardial ischemia by using mitochondrial uncoupling agents (carbonyl cyanide m-chlorophenylhydrazone and 2,4-dinitrophenol) and channel blockers (5-hydroxydecanoate and cyclosporine A) at concentrations that have been demonstrated to block the intended targets selectively. Isolated rat hearts (n = 8 per group) were perfused with 0.3 µM carbonyl cyanide m-chlorophenylhydrazone, 100 µM 2,4-dinitrophenol, 0.2 µM cyclosporine A, 100 µM 5-hydroxydecanoate, or vehicle solution and regional ischemia induced after 10 minutes. Carbonyl cyanide m-chlorophenylhydrazone and 2,4 dinitrophenol caused profound QT shortening and triggered VF in 100% of hearts before ischemia. During ischemia, neither cyclosporine A (88%) nor 5-hydroxydecanoate (100%) reduced VF incidence compared with control (100% VF). In separate hearts, carbonyl cyanide m-chlorophenylhydrazone decreased tissue ATP content, and glibenclamide or glimepiride delayed the QT shortening and onset of VF triggered by carbonyl cyanide m-chlorophenylhydrazone. In conclusion, mitochondrial uncoupling agents trigger VF, likely as a result of ATP depletion with subsequent activation of sarcolemmal ATP-sensitive K+ currents. The mechanism of VF in ischemia does not involve activation of the mitochondrial ATP-sensitive K+ channel or permeability transition pore.

From one addiction to another: life after alcohol and drug abuse.

Once the alcoholic or drug addict has stopped drinking or using drugs, other addictive behaviors are frequently adopted. These factors must be considered in planning the overall recovery program. Substances likely to be used to excess include nicotine, caffeine, sugar, chocolate, nutritional supplements and medicinal herbs. Addictive behaviors adopted by recovering persons include eating disorders, exercise and body building, workaholism, and dependency on one's own adrenalin. Breaking the cycle of addiction requires commitment to a program of self-growth and becoming responsible for one's actions.

Chronic schizophrenic women's attitudes toward sex, pregnancy, birth control, and childrearing.

Interviews with 23 chronically institutionalized, schizophrenic women living on a chronic care unit indicated that the majority had a continuing interest in sex and engaged in sexual activity. Fourteen of the women wanted to become pregnant. Few seemed to recognize their limited potential to be adequate parents. Respondents often gave bizarre or inaccurate responses to the interview questions, indicating that their ideas about contraception, pregnancy, and childrearing were affected by psychopathology. The authors concede that the task of designing and implementing birth control programs for severely ill schizophrenic patients is formidable but encourage mental health professionals to openly discuss sex, birth control, and having children with their patients.

PIP: Interviews with 23 chronically institutionalized, schizophrenic women living on a chronic care unit and ranging in age from 20-58 years were interviewed to provide initial systematic data about the attitudes of chronic schizophrenic women toward sex, pregnancy, birth control, and childrearing. All of the subjects, patients at the Middle Tennessee Mental Health Institute, had been receiving neuroleptic medications for at least 3 months before they were interviewed. All had some outside grounds privileges allowing them to have unsupervised contact with male patients. Subjects had been continuously hospitalized for a minimum of 3 months. 2 of the women were married. 12 of the 23 women had borne children. The number of children ranged up to 9. At the time of the interview, 2 women were not using contraceptives, 9 were taking oral contraceptives (OCs), 1 had an IUD, and 2 had had tubal ligations. 1 women had had a hysterectomy, and 8 had already gone through menopause. Each patient was interviewed by the ward charge nurse (AH) who had become well acquainted with the patients during many months and even years of care. 13 of the 23 women reported they would like to have an active sex life. After describing the kind of man they would find attractive, 16 of the women reported they would not hesitate to have sex with such a man if the opportunity were available. 15 reported having had intercourse during the previous 3 months. The frequency of intercourse ranged from once during the entire 3 months to once a day during that period. The nursing staff who constantly worked with these women judged that 14 probably had been sexually active during the 3 months before the interview. 6 of the women reported they would currently like to become pregnant. 8 said they would like to become pregnant in the future. 9 reported no desire to become pregnant. 8 said they would currently like to have children or more children; 6 said they would not like to have more children now but would like to do so in the future. The 3 women who had been surgically sterilized all said they wanted to become pregnant and have more children. Despite the majority's accurate description of birth control, when the women were questioned about its advantages, only 10 understood that women could use birth control to avoid pregnancy. Psychopathology, manifested in unusual responses and inaccurate answers, often disrupted the reasoning of these patients and could potentially lead to illogical conclusions and imprudent activities.