If we build it, they will come: Caregiver decision to use an accessible outpatient psychiatric service for children and adolescents in Nigeria.

OBJECTIVE: If child and adolescent psychiatric (CAP) services were accessible in lower-middle-income countries (LMIC) such as Nigeria, what individual and socio-cultural factors would influence caregivers' willingness to use these services when they are needed? METHODS: To address this question, we conducted structured interviews with a stratified random sampling of 442 adult caregivers of children aged 5 to 19-years who lived within 10 km of an established CAP outpatient service in Ibadan, Nigeria. RESULTS: Based on structural equation modeling, our cross-sectional findings indicated that caregivers were generally willing to use the accessible outpatient CAP service for a narrow range of overtly disruptive and developmentally atypical child behavior. However, their decisions were not influenced by their recognition of child and adolescent mental health (CAMH) conditions, competing life stressors, caregiver wellness, nor stigma as we had initially hypothesized. Rather caregivers pragmatically considered a range of approaches to address CAMH concerns. Post-hoc hypotheses confirmed that caregivers' beliefs about etiology and treatment effectiveness for CAMH conditions shaped their help-seeking decisions and stigmatization of CAP services. Specifically, caregivers who attributed CAMH conditions to physical causes regarded biomedical interventions as the most effective treatment while spiritual interventions were deemed to be the least effective. CONCLUSIONS: Taken together our results suggested that caregivers were receptive and willing to use outpatient psychiatric services for their children. However, their beliefs about the etiology and treatment effectiveness of CAMH conditions shaped how they intended to engage the services. These findings underscored the importance of scaling up a broader spectrum of accessible complementary CAMH intervention and prevention services in Nigeria that extend beyond indigenous or biomedical models. In doing so caregivers will come.

Navigating Stigma Trajectory and Mental Health Among Young Adults Living with Perinatal HIV in New York City.

Perceived HIV stigma and mental health are fluid across the lifespan for people living with perinatally-acquired HIV (PHIV). The process of navigating discredited identities over time in the context of other life demands potentially exerts a toll on the mental health of adolescents and young adults living with PHIV (AYAPHIV). Based on data from a longitudinal study in New York City examining mental health and health risk behaviors among 182 AYAPHIV, we examined if increased perceived HIV stigma predicted mental health, future orientation, HIV-disclosure, and healthcare transition over time (2003-2018). Findings from linear mixed-effects modeling indicated that older age predicted poorer mental health, less future orientation, more HIV-serostatus disclosure, and adult medical services utilization. Perceived stigma was the only significant predictor of mental health and mediated the association between age and mental health-highlighting the importance of addressing stigma across development for AYAPHIV while addressing systems that perpetuate them.

Ethnoracial patterns of violence in Guatemala: An empirical examination of the relationship between Mayan-majority municipalities and homicide rates in Guatemala.

The current study empirically tests the relationship between homicide rates and the population of indigenous Mayans at the municipal level in Guatemala. Using data from the most recent Guatemalan Census (2018) and independently aggregated national police data on homicides, we also propose models of possible pathways for the relationship between the ethnoracial composition of municipal population and homicide rates. Due to consistent non-normal distribution of demographic data in Guatemala, we used a maximum likelihood estimation of linear regression models and nonparametric bootstrapping method to test the theoretical relationships. The results showed a strong negative relationship between Mayan majority municipalities and homicide rates, mediated by living in municipality of birth. Findings suggest that attachment to place in Mayan majority municipalities in Guatemala is a strong protective factor for exposure to homicide, even in areas of high out-migration.

Livelihood intervention and mental well-being among women living with HIV in Delhi.

ABSTRACTPoverty-alleviation programmes aimed to improved mental well-being among persons living with HIV (PLWH) in low and middle income countries have underscored the importance of understanding how and why such programmes work. We present findings from a six-month ethnographic process evaluation of Kiran, an economic livelihood programme locally designed to improve mental well-being among women affected by HIV in Delhi, India. In addition to benefits of improved economic standing, we found that supportive relationships cultivated among participants (n = 9) and with providers (n = 3) provided respite from worry about their illness and reframed what was relationally and practically possible in the context of living with HIV. In acquiring marketable craft skills with peers, participants challenged internalized scripts of being socially devalued and regained agency about their abilities to contribute to their community and support their children's immediate and future needs. We found that the benefits of Kiran weighed less on the direct alleviation of mental distress and more on the instillation of hope for their children. Our findings exemplify the importance of re-visiting a priori theories that inform interventions for PLWH and highlight the methodological merits of ethnographic approaches that underscore how theory and intervention praxis are bidirectionally informed.

A Winding Road to Peace Building: Longitudinal Outcomes of a Peace Intervention for Survivors and Génocidaires of the 1994 Genocide Against the Tutsi in Rwanda.

This longitudinal study examined outcomes of a local peace-building intervention that applied principles of intergroup contact to promote reconciliation between génocidaires and survivors whom they have directly harmed during the 1994 Genocide Against the Tutsi in Rwanda. Individual interviews were conducted with 46 génocidaires and 45 survivors whom they have directly harmed during the genocide at 7-time points over the course of their 22-month participation in three programmatic activities (workshops, cell groups, and cooperative cow raising). One thousand bootstrapped samples generated to measure changes in outcomes indicated that survivors and génocidaires regarded themselves and those who directly impacted them during the genocide more positively after 22 months. Although both survivors and génocidaires experienced significant decline in trauma symptomatology after 22 months, they responded to programmatic activities differently. Cell group interactions sustained some positive outcomes (génocidaires perceived forgiveness by others) after the workshops and further improved others (génocidaires self-forgiveness). Survivors who participated in cell groups and raised cows with génocidaires demonstrated further willingness to reconcile compared to survivors who participated in cell groups alone. Our findings empirically support the benefits of promoting different forms of intergroup interactions long after a period of intense violence and highlight the importance of considering how the trajectories of outcomes can inform program and theory development. HIGHLIGHTS: Survivors and génocidaires in Rwanda benefited from a local intergroup contact intervention (CI). However, génocidaires and survivors they directly harmed benefited differently over 22-months. Preparing survivors and génocidaires with skills to participate in communal life is critical for CI. Highlighting both CI outcomes and trajectories are essential for program and theory development.

Caregiver perceptions of environment moderate relationship between neighborhood characteristics and language skills among youth living with perinatal HIV and uninfected youth exposed to HIV in New York City.

Despite the increased recognition of how neighborhood conditions bear on cognitive and academic outcomes, no studies have examined the influences of objective and subjective neighborhood indices on specific areas of cognitive functioning among youth living with perinatal HIV (PHIV). In the United States (US), this is of particular concern as HIV has disproportionately affected African American youth living in economically disadvantaged and racially segregated communities. Thus, based on a longitudinal cohort study of psychosocial and behavioral health outcomes in 340 perinatally HIV-exposed but uninfected (PHEU) and PHIV youth residing in New York City, ages 9-16 years at enrollment, we analyzed data from baseline and multiple follow-up (FU) quantitative interviews with youth and their primary caregivers, from when they were at least 13-years-old (approximately 4-6 years post enrollment). We examined the association between baseline neighborhood indices (2000 US census data and caregiver's perception of neighborhood stressors) and youth receptive language skills (PPVT; Peabody Picture Vocabulary Test) at FU2 and FU3. Census data (percentage of families in neighborhood living below the national poverty rate, median neighborhood household income, and percentage of residents professionally employed) were not independently associated with PPVT scores at both follow-ups. However, in the logistic regression model, the more caregivers perceived their neighborhood as stressful and subjected to violence, the stronger the relationship between census data indicators of low resource neighborhoods and lower PPVT scores for both groups. Findings support "place-based" policies and practices that alleviate caregiver experiences of neighborhood stressors which may contribute to improved cognitive outcomes for youth living with and affected by PHIV.

Understanding HIV Transmission and Illness Stigma: A Relationship Revisited in Rural Rwanda.

Integrating an understanding of HIV transmission with structural-behavioral prevention approaches remains a priority in low prevalence rural regions in Africa. Many national indicators use categorical survey responses which do not capture the cultural nuances of HIV transmission knowledge that potentially reify stigmatizing treatment of persons living with HIV (PL-HIV). We examined the relationship between quantitative and qualitative measures of HIV knowledge and four forms of stigma (individual attitudes, felt normative, social distance, and stigma perceived by PLHIV) among 200 rural residents in Rwanda. Forty-two percent qualitatively reported concurrent accurate and partial knowledge of HIV transmission. Being more knowledgeable about HIV transmission was associated with less desire for social distancing from PLHIV. Our findings highlight the continued importance of reinforcing an accurate understanding of HIV transmission and correcting misinformation by drawing on quantitative and qualitative assessments of HIV knowledge as critical arms of HIV stigma reduction programs in low prevalence rural regions.

Poverty indicators and mental health functioning among adults living with HIV in Delhi, India.

Poor mental health functioning among persons living with HIV (PLHIV) has gained considerable attention particularly in low-income countries that disproportionately carry the global HIV/AIDS burden. Fewer studies, however, have examined the relationship between poverty indicators and mental health among PHLIV in India. Based on this cross-sectional study of 196 HIV-seropositive adults who received medical services at Shalom AIDS Project in Delhi, India, structural equation modeling and mediation analysis were employed to estimate the associations between poverty indices (household asset index, food security, unemployment, water treatment, sanitation), HIV-health factors (illness in the past 3 months, co-morbid medical conditions), and psychological distress. In the final model, ownership of fewer household assets was associated with higher levels of food insecurity, which in turn was associated with higher psychological distress. Also, the household asset index, food insecurity, and unemployment had a larger effect on psychological distress than new opportunistic infections. These findings build on increasing evidence that support concerted efforts to design, evaluate, and refine HIV mental health interventions that are mainstreamed with livelihood programming in high poverty regions in India.

Factors associated with high rates of antiretroviral medication adherence among youth living with perinatal HIV in Thailand.

Antiretroviral medication adherence behaviour among Thai youth with perinatal HIV in Thailand has received growing attention. However, few studies have examined individual predictors of antiretroviral adherence using multiple self-reports. A convenience sample of 89 Thai youth (interquartile range 14-16 years) with perinatal HIV at three paediatric programmes in Chiang Mai completed a structured questionnaire and reported their antiretroviral adherence in the past one, seven and 30 days using count-based recall and a visual analog scale. Mean self-reported adherence rates ranged from 83.5% (past 30 days) to 99.8% (yesterday) of the time. One-inflated beta regression models were used to examine the associations between antiretroviral adherence outcomes, treatment self-efficacy, depression, anxiety, social support and beliefs/attitudes about medications. Higher percentage of medications taken in the past 30 days was independently associated with higher treatment self-efficacy and fewer symptoms of depression. Adherence monitoring would benefit from focal assessment of youth depression and perceived capacity to follow their antiretroviral regimen.

Influences of stigma and HIV transmission knowledge on member support for faith-placed HIV initiatives in Chinese immigrant Buddhist and protestant religious institutions in New York City.

Ethnic religious institutions in the United States are uniquely positioned to influence HIV programming within Asian immigrant communities at large. This article examines how knowledge of HIV transmission and stigma potentially influenced attendees' support for their institutions' involvement in HIV programs. Quantitative questionnaires were individually administered to 400 Chinese attendees of Protestant churches and 402 attendees of Buddhist temples in New York City. Mediational analyses indicated that HIV stigma significantly mediated the direct effects of HIV transmission knowledge on attendees' support of their institution's involvement in HIV education (bias corrected and accelerated [BCa] 95% confidence interval [CI], 0.004 to 0.051), HIV care (BCa 95% CI, 0.019 to 0.078), and stigma reduction initiatives (BCa 95% CI, 0.013 to 0.070), while controlling for religious affiliation, age, gender, and education. To mobilize Chinese churches and temples to engage in HIV programming, it remains important to support educational programs on HIV transmission that specifically help to mitigate stigma toward persons living with HIV.

A prospective study of the onset of sexual behavior and sexual risk in youth perinatally infected with HIV.

Perinatally HIV-infected (PHIV+) youth are surviving into adolescence and young adulthood. Understanding the sexual development of PHIV+ youth is vital to providing them with developmentally appropriate HIV-prevention programs. Using pooled data (N = 417) from two longitudinal studies focused on HIV among youth (51% female; 39% HIV+) and their caregivers (92% female; 46% HIV+), the rate of sexual onset during adolescence across four youth-caregiver combinations was compared: PHIV+ youth with HIV+caregivers (12%), PHIV+ youth with HIV- caregivers (27%), HIV- youth with HIV+caregivers (34%), and HIV- youth with HIV- caregivers (27%). Youth with HIV- caregivers were more likely than other youth-caregiver groups to have had their sexual onset. Youth with HIV+ caregivers reported a slower rate of onset of penetrative sex across the adolescent years. Findings are discussed by highlighting the role that both youth and caregiver HIV status play in the onset of sexual behavior across adolescence.

Civic/sanctuary orientation and HIV involvement among Chinese immigrant religious institutions in New York City.

Using data from a study of Chinese immigrant religious institutions in New York City (primarily Christian and Buddhist), this paper explores why some religious institutions are more inclined than others to be involved in HIV-related work. Although numerous factors are likely to play a role, we focus on organisations' differing views on social engagement as an explanatory factor. We hypothesise that religious institutions that value social engagement ('civic') will be more inclined towards HIV/AIDS involvement than those that are more inward focused ('sanctuary'). Given that many religious institutions are fundamentally defined by their stance on the appropriateness of social engagement, better understanding of this key characteristic may help to inform community and government organisations aiming to increase religious institutions' involvement in HIV/AIDS-related work. Our analysis suggests that some organisations may be less interested in taking on the challenges of working in HIV/AIDS because of their general view that churches or temples should not be socially engaged. On the other hand, religious institutions that have concerns about social acceptability, fear of infection or lack of capacity--but generally embrace social engagement--may be more open to partnering on HIV/AIDS-related work because of their overriding community service orientation.

DISADVANTAGED NEIGHBORHOOD INFLUENCES ON DEPRESSION AND ANXIETY IN YOUTH WITH PERINATALLY ACQUIRED HUMAN IMMUNODEFICIENCY VIRUS: HOW LIFE STRESSORS MATTER.

Children living with perinatal HIV illness (PHIV+) disproportionately reside in disadvantaged neighborhoods and contend with persistent mental health challenges. This study examined the influences of disadvantaged residential neighborhood on anxiety and depression, and potential resources that buffer against internalizing problems when youths were exposed to neighborhood stressors. Multilevel analysis of 196 PHIV+ and 129 perinatally HIV-exposed but uninfected youth (PHIV-) in New York City found that higher exposure to neighborhood disorder was associated with higher levels of depression and anxiety for PHIV+ and PHIV- youths. Stressful events unrelated to residential neighborhoods significantly mediated the relationship between neighborhood disorder and anxiety and depression. Social problem solving and religiosity did not moderate the relationship between neighborhood disorder and internalizing problems. Our findings highlighted that interventions that attenuate the negative effects of stressful life events were equally critical in addressing the broader impact of disadvantaged neighborhoods on the mental health of youth affected by HIV.

Faith-Based HIV Care and Prevention in Chinese Immigrant Communities: Rhetoric or Reality?

Ethnic churches attended by first generation Chinese immigrants are uniquely positioned to address emerging HIV prevention and care needs within the Chinese community at-large. Efforts to develop faith-based HIV programs necessitate identifying how HIV intersects with the sinicization of Christianity within Chinese churches. This paper will review the process of contextualizing HIV within theological and cultural frameworks that are meaningful for ethnic Chinese church leaders and members. The authors specifically propose two points of integration between public health and ecclesial functions: (1) HIV stigma-mitigation initiatives as informed by Christo-centric teachings of compassion and justice, and (2) HIV prevention and care reframed as social responsibility and informed by the Christian tradition of evangelism. Systems and practices that hinder and promote the involvement of Chinese churches in HIV prevention, care, and stigma-reduction will be discussed.

The impact of perinatal HIV infection on older school-aged children's and adolescents' receptive language and word recognition skills.

Perinatally HIV-infected youths are reaching adolescence in large numbers. Little is known about their cognitive functioning. This study aims to describe and compare the receptive language ability, word recognition skills, and school functioning of older school-aged children and adolescents perinatally HIV infected (HIV-positive) and perinatally HIV-exposed but uninfected (seroreverters; HIV-negative). Participants included 340 youths (206 HIV-positive, 134 HIV-negative), 9-16 years old, and their caregivers. Youths completed the Peabody Picture Vocabulary Test, Third Edition (PPVT-III) and the Reading Subtest of the Wide Range Achievement Test, Third Edition (WRAT-3). Caregivers were interviewed regarding demographic characteristics and school placement of youths. Medical information was abstracted from medical charts. Both groups of youths scored poorly on the PPVT-III and WRAT-3 with about one third of youths scoring in less than the 10th percentile. The HIV-positive youths scored lower than the seroreverters (M = 83.8 versus 87.6, t = 2.21, p = 0.028) on the PPVT-III and on the WRAT-3 (M = 88.2 versus 93.8, t = 2.69, p = 0.008). Among the HIV-positive youths, neither CD4+ cell count, HIV RNA viral load or Centers for Disease Control and Prevention (CDC) classification were significantly associated with either PPVT-III or WRAT-3 scores. However, youths who were taking antiretroviral medication had lower WRAT-3 scores than youths not taking medication (M = 95.03 versus 86.89, t = 2.38, p = 0.018). HIV status remained significantly associated with PPVT-III and WRAT-3 standard scores after adjusting for demographic variables. Many youths had been retained in school and attended special education classes. Findings highlight poor language ability among youths infected with and affected by HIV, and the importance of educational interventions that address this emerging need.

Brief report: language ability and school functioning of youth perinatally infected with HIV.

INTRODUCTION: The purpose of this article is to describe the language ability and school functioning of early adolescents with perinatal HIV/AIDS. METHOD: Participants included 43 youths, 9-15 years, and their primary caregivers. Youths completed the Peabody Picture Vocabulary Test (PPVT) and the Reading Subtest of the Wide Range Achievement Test (WRAT3) and were interviewed regarding their future educational aspirations and parental supervision and involvement with homework. Caregivers were interviewed regarding the child's school achievement, parental supervision and monitoring, and educational aspirations for their child. RESULTS: Fifty-four percent of youths scored below average (<25th percentile) on the PPVT, and 29% scored below the 10th percentile; 40% scored below average (<25th percentile) on the WRAT3, and 24% scored below the 10th percentile. Scores were associated with parental monitoring and educational aspirations. DISCUSSION: Youths performed poorly on tests of verbal and reading ability, although their scores were not dissimilar to those of other samples of inner-city youths. Future research should attempt to isolate the impact of HIV disease on intellectual and school functioning of HIV+ youths.

Are psychological consequences of stigma enduring or transitory? A longitudinal study of HIV stigma and distress among Asians and Pacific Islanders living with HIV illness.

Cross-sectional findings have shed considerable light on the relationships between illness stigma and psychological outcomes among persons living with HIV/AIDS in the United States. However, no studies have examined the possible long-term consequences of illness stigma on mental health among Asians and Pacific Islanders living with HIV/AIDS, a group particularly vulnerable to HIV stigma due to ingrained sociocultural norms. This 2-year longitudinal study examined the relationship between five HIV-stigma factors (social rejection, negative self-worth, perceived interpersonal insecurity, financial insecurity, discretionary disclosure) and changes in psychological distress dimensions (self-esteem, hopelessness, dread, confused thinking, sadness, anxiety) among a convenience sample of 44 HIV-seropositive Asians and Pacific Islanders in New York City from 2002 to 2004. Undocumented Asians independently endorsed higher levels of perceived interpersonal insecurity and lower levels of self-esteem than documented participants at both baseline and 2-year follow-up. Results from hierarchical multiple regression analyses indicated that baseline social rejection and perceived interpersonal insecurity were significantly associated with changes in self-esteem at 2-year follow-up, controlling for baseline self-esteem and physical symptoms at follow-up. An interaction effect between baseline financial insecurity and discretionary disclosure was significantly associated with dread at 2-year follow-up. Findings highlight the importance of stigma reduction interventions that: (1) recognize multiple layers of stigma based sexual orientation, gender, and immigration status; and (2) address both individual and structural constraints that perpetuate HIV-stigma among Asians and Pacific Islanders in the United States.

Serving Asians and Pacific Islanders with HIV/AIDS: challenges and lessons learned.

This paper reports on findings from an evaluation of the Bridges Project, a community-based intervention implemented at the Asian and Pacific Islander Coalition on HIV/AIDS (APICHA), to reduce disparities in care for Asians and Pacific Islanders (APIs) living with HIV/AIDS in New York. Comparisons of participants by primary language (Asian language vs. English) and immigration status (undocumented vs. documented/citizen) show that Asian-primary-language and undocumented participants at baseline had a significantly lower rate of receipt of primary care services and experienced significantly more barriers per service than English-primary-language and documented participants. At follow-up, however, differences by primary language and immigration status disappeared, indicating that the Bridges Project was effective in improving service utilization and reducing barriers for the Asian-primary-language and undocumented participants. Barriers to services reported most frequently by participants were language and cost barriers, not knowing where to go for services, and confidentiality concerns. Study findings indicate that the capacity to address multiple API languages and cultures is essential in providing culturally competent care to APIs living with HIV.

Multiple dimensions of HIV stigma and psychological distress among Asians and Pacific Islanders living with HIV illness.

Asians and Pacific Islanders (APIs) living with HIV/AIDS in the US are particularly vulnerable to HIV-related stigma largely due to ingrained socio-cultural norms that strongly associate HIV transmission with activities perceived to be immoral. This cross-sectional study examined the relationship between five HIV-stigma factors and psychological distress among 54 HIV-seropositive APIs. Social Rejection, Negative Self-Worth, Perceived Interpersonal Insecurity, and Financial Security were all significantly associated with psychological distress. Results from hierarchical multiple regression analyses indicated that Social Rejection, Negative Self-Worth, and Perceived Interpersonal Insecurity significantly predicted psychological distress after control for physical symptoms and country of birth. Undocumented Asians endorsed higher levels of Social Rejection, Negative Self-Worth and Perceived Interpersonal Insecurity than documented APIs. Future studies examining mechanisms of psychological distress among HIV-seropositive APIs are needed.

The "Demon Plague" and access to care among Asian undocumented immigrants living with HIV disease in New York City.

Access to and utilization of care for HIV-positive Asians (A) and Pacific Islanders (PI) have been largely unaddressed despite the rising influx of immigrants from Asia and the Pacific to the United States and the growing HIV prevalence in these regions. This paper describes the cultural attitudes, behaviors, and perceptions that affect access to and utilization of care among Asian undocumented noncitizens living with HIV/AIDS (UNWHA) in New York City. Sixteen semistructured interviews with HIV-positive UNWHAs revealed that their access to care was influenced by community misperceptions of HIV transmission, discriminatory attitudes towards persons living with HIV, competing immigration related stressors, and difficulty navigating service systems. These findings underscore the importance of integrating HIV treatment with primary prevention and awareness of immigration-related stressors to ensure timely access to screening services and care among Asian UNWHAs.