Abstract
We assessed the effect of depression, hopelessness, and self-concept on HIV prevention attitudes and knowledge about infection, transmission and sexual risk behavior among adolescents living with HIV in Uganda. Utilizing longitudinal data from 635 adolescents living with HIV, multiple ordinary least square regression was used to evaluate associations between the three indicators of mental health functioning at baseline and HIV knowledge and prevention attitudes at 12-months follow-up. We found that depression (β = − 0.17; 95% CI − 0.31, − 0.04) and hopelessness (β = − 0.16; 95% CI − 0.28, − 0.04) scores at baseline were associated with a 0.17 and 0.16 average reduction in HIV prevention attitudes and HIV knowledge scores, respectively at 12-months follow-up. However, self-concept was not significantly associated with HIV knowledge or prevention attitudes. Adolescents living with HIV with greater levels of hopelessness are at increased risk of having limited HIV knowledge while those with greater symptoms of depression had less favorable HIV prevention attitudes.
Keywords: Adolescent, HIV, Knowledge, Attitude, Mental health
Introduction
Sub-Saharan Africa (SSA), a low-resourced region, carries a disproportionate burden of people living with HIV, accounting for more than 70% of the global burden of HIV infection and over 80% of youth (ages 15–24 years) living with HIV reside in the SSA region [1]. Adolescent girls and young women carry an even greater burden, with almost two out of three daily infections occurring in this population [1]. Within SSA, Uganda has one of the highest burdens of adolescents living with HIV (ALWHIV) [2], coupled with high levels of poverty [3]. Uganda’s population of ~ 45 million comprises ~ 50% of children younger than 15 years [4], and among these the total HIV prevalence was 0.5% [5]. Among Ugandan youths aged 15–24 years, HIV prevalence was ~ 4 times higher among females than males [6].
Moreover, research indicates that mental health, including both emotional, and behavioral challenges are significantly prevalent among ALWHIV, including those in low-resource settings [7–9]. Research among ALWHIV populations residing in low- and middle-income countries found that depression [10–12], anxiety disorders [10], psychological distress [12], emotional and behavioral difficulties, trauma [8, 13], and attempted suicide [12, 14] are common. Additionally, ALWHIV mental health problems may be exacerbated by experiences related to discrimination, poverty [15], feelings of self-blame and stress over societal stigma and social exclusion [16].
These mental health challenges have been shown to be associated with lower adherence to antiretroviral therapy (ART) [9], and higher sexual risk-taking, including condomless sex among ALWHIV, which, in combination with higher viral load increases the risk of HIV transmission to others [17]. However, limited information on how mental health challenges impact ALWHIV’s knowledge about HIV disease, knowledge about the importance of adherence for maintaining the best health, ways to prevent transmission to uninfected persons and their attitudes towards preventing transmission have not been explored. These variables have all been associated with adherence and prevention behaviors and thus are critical to efforts to end the HIV epidemic both through promotion of ALWHIV health and prevention of transmission to others.
Given the aforementioned, it is critical to understand the impact of mental health on ALWHIV knowledge about HIV and transmission as well as their attitudes towards preventing transmission. This is important because having the correct knowledge about HIV transmission and favorable attitudes towards HIV prevention, although not guaranteed, is an important prerequisite for practicing safer sexual behaviors during adolescence. It is also necessary for reducing the risk of secondary re-infection with resistant strains of HIV and/or reducing the risk of co-infection with Hepatitis B or Hepatitis C, which negatively affects health outcomes among people living with HIV [18]. Correct knowledge about HIV, and its transmission, along with favorable attitudes towards HIV prevention, can empower ALWHIV to practice safer sexual behaviors, adhere to medication and practice better self-care management that leads to improved overall quality of life. More importantly, correct knowledge about HIV transmission and favorable prevention attitudes can protect uninfected individuals from infection.
The behavioral capability construct of social cognitive theory argues that accurate information and increased awareness of knowledge are a pre-requisite for behavior change [19]. In other words, in order for a person to successfully perform a behavior, a person must know what to do and how to do it. Therefore, in the context of HIV prevention and reduction of transmission, accurate knowledge is a necessary first step for actual behavior change. Given the limited published information on HIV transmission knowledge and attitudes towards prevention among ALWHIV with mental health challenges, the present study aims to assess the impact of mental health functioning on attitudes towards prevention and knowledge about HIV and transmission among ALWHIV in southern Uganda.
Methods
Study Design
The present study utilized baseline and 12-month follow-up data from a 6-year National Institutes of Health funded longitudinal study called ‘Suubi + Adherence’ (2012–2018), conducted in 39 health centers/clinics in six geographical districts (Masaka, Kalungu, Lwengo, Rakai, Kyotera, and Bukomansimbi) in Southwestern Uganda [20].
This is a region heavily impacted by HIV/AIDS. At the time of the study, the prevalence in the region (12%) was higher than the national levels (9%) [21]. A total of 702 ALWHIV participated in the Suubi + Adherence study. Although 702 participants were interviewed at baseline, the current analyses were conducted on 635 complete cases, which is an acceptable level of missing data (less than 10% [22]). Participants were eligible to be included in the study if they were: (1) medically diagnosed with HIV and aware of their HIV status; (2) living within a family (not necessarily biological parents, but not an institution); (3) aged 10–16 at baseline; (4) prescribed ART medication and; (5) receiving HIV care and treatment at one of 39 participating health centers/clinics accredited by Uganda’s Ministry of Health in the study region. Although we did not capture the mode of transmission for HIV infection, given the local context and the mean age of participants (mean = 12.3 years), the majority of the included adolescents are likely to be perinatally infected. Prior to study participation, adolescents had to be aware of their HIV status to avoid unintentional disclosure.
Participants were recruited from 39 health clinics and randomized at the health clinic level to either a combination intervention arm or a control arm receiving usual care. All selected adolescents in the same clinic/health center received the same intervention, to reduce contamination. Participants were assessed at baseline and 12 months follow-up using standardized culturally adapted assessments used in gathering data from HIV- affected populations in sub-Saharan Africa. Notably, the delivery of health education sessions in Uganda varies substantially across clinics/health facilities. Therefore, to address this variation, the study provided six sessions on HIV/AIDS knowledge and prevention, stigma, and ART adherence to all participants using a cartoon-based curriculum. A full description of the study protocol has been published elsewhere [20].
Data were collected using a 90-min interviewer administered survey. The survey captured several outcome measures including mental health, family functioning, academic outcomes, savings, family assets and knowledge about HIV/AIDS and prevention attitudes. Survey instruments were translated into Luganda (language spoken in the study region) and back translated into English to ensure accuracy. This process was overseen by certified language experts at the Makerere University institute of languages in Uganda. Before interacting with participants, research assistants received training in Good Clinical Practices and Collaborative Institutional Training Initiative (CITI).
Assessment of HIV/AIDS Knowledge (Infection, Transmission and Sexual Risk Behavior)
Participants’ knowledge about HIV were assessed at 12-months follow-up. Participants were given 24 statements about an activity related to HIV transmission, risk-behavior, prevention, stigma, medication adherence, viral load, and testing measures. They were asked to select if they thought the activity was safe = 3, unsafe = 2, or not sure = 1 or true = 3, false = 2 or unsure = 1 (refer to Table 1 for description and distribution of responses to the statements provided). For this analysis, correct answers were recoded to have higher scores and incorrect and unsure answers were recoded to have lower scores. The scores from all 24 statements were summed to get a total HIV knowledge score, with higher scores representing greater knowledge.
Table 1.
Description of ALWHIV’s HIV Knowledge assessments and distribution of responses at baseline and 12 months follow-up
| Baseline | 12 months | ||||||||
|---|---|---|---|---|---|---|---|---|---|
| Total sample | Males | Females | X2 (P) | Total sample | Males | Females | X2 (P) | ||
| HIV/AIDS knowledge assessment questions | Categories | N = 635 n (%) | N = 281 n (%) | N = 354 n (%) | N = 635 n (%) | N = 281 n (%) | N = 354 n (%) | ||
| Select if safe, unsafe, or unsure | |||||||||
| Sharing needles or syringes (empiso) with an HIV-infected person | Correct | 510 (80.3) | 217 (77.2) | 293 (82.8) | 3.0 (0.08) | 522 (82.2) | 238 (84.7) | 284 (80.2) | 2.2 (0.14) |
| Incorrect | 125 (19.7) | 64 (22.8) | 61 (17.2) | 113 (17.8) | 43 (15.3) | 70 (17.8) | |||
| Having unprotected sex with an HIV-infected person | Correct | 502 (79.1) | 217 (77.2) | 285 (80.5) | 1.0 (0.31) | 518 (81.6) | 241 (85.8) | 277 (78.3) | 5.9 (< 0.05) |
| Incorrect | 133 (20.9) | 64 (22.8) | 69 (19.5) | 117 (18.6) | 40 (14.2) | 77 (21.7) | |||
| Holding hands with an HIV-infected person | Correct | 311 (49.0) | 127 (45.2) | 184 (52.0) | 2.9 (0.09) | 313 (49.3) | 160 (56.9) | 153 (43.2) | 11.8 (< 0.001) |
| Incorrect | 324 (51.0) | 154 (54.8) | 170 (48.0) | 322 (50.7) | 121 (43.1) | 201 (56.8) | |||
| Touching toilet seats, spoons, cups, or other objects after a person infected with HIV/AIDS | Correct | 255 (40.2) | 95 (33.8) | 160 (45.2) | 8.5 (< 0.01) | 267 (42.1) | 130 (46.3) | 137 (38.7) | 3.7 (< 0.05) |
| Incorrect | 380 (59.8) | 186 (66.2) | 194 (54.8) | 368 (58.0) | 151 (53.7) | 217 (61.3) | |||
| Kissing a person who is infected with HIV/AIDS | Correct | 127 (20.0) | 53 (18.9) | 74 (20.9) | 0.41 (0.52) | 135 (21.3) | 65 (23.1) | 70 (19.8) | 1.1 (0.30) |
| Incorrect | 508 (80.0) | 228 (81.1) | 280 (79.1) | 500 (78.7) | 216 (76.9) | 284 (80.2) | |||
| Select if true, untrue, or unsure | |||||||||
| You can look at a person and tell if they are infected with HIV/AIDS | Correct | 249 (39.2) | 100 (35.6) | 149 (42.1) | 2.8 (0.09) | 273 (43.0) | 107 (38.1) | 166 (47.0) | 4.9 (< 0.05) |
| Incorrect | 386 (60.8) | 181 (64.4) | 205 (57.9) | 362 (57.0) | 174 (61.9) | 188 (53.0) | |||
| A pregnant woman who has HIV/AIDS can give her unborn baby the virus | Correct | 402 (63.3) | 189 (67.3) | 213 (60.2) | 3.4 (0.07) | 402 (63.3) | 186 (66.2) | 216 (61.0) | 1.8 (0.18) |
| Incorrect | 233 (36.7) | 92 (32.7) | 141 (39.8) | 233 (36.7) | 95 (33.8) | 138 (39.0) | |||
| There is a cure for HIV/AIDS | Correct | 246 (38.7) | 103 (36.6) | 143 (40.4) | .92 (.34) | 286 (45.0) | 120 (42.7) | 166 (46.9) | 1.11 (0.29) |
| Incorrect | 389 (61.3) | 178 (63.4) | 211 (59.6) | 349 (55.0) | 161 (57.3) | 188 (53.1) | |||
| If a woman is using birth control pills, she is protected from HIV infection | Correct | 191 (30.1) | 90 (32.0) | 101 (28.5) | 0.91 (0.34) | 220 (34.7) | 94 (33.5) | 126 (35.6) | 0.32 (0.57) |
| Incorrect | 444 (69.9) | 191 (68.0) | 253 (71.5) | 415 (65.4) | 187 (66.5) | 228 (64.4) | |||
| You can get HIV from a mosquito bite | Correct | 319 (50.2) | 126 (44.8) | 193 (54.5) | 5.9 (< 0.05) | 354 (55.8) | 157 (55.9) | 197 (55.7) | 0.003 (0.96) |
| Incorrect | 316 (49.8) | 155 (55.2) | 161 (45.5) | 281 (44.3) | 124 (44.1) | 157 (44.3) | |||
| You can get HIV from using the same washing basin with an HIV infected person | Correct | 332 (52.3) | 130 (46.3) | 202 (57.1) | 7.3 (< 0.01) | 364 (57.3) | 164 (58.4) | 200 (56.5) | 0.22 (0.64) |
| Incorrect | 303 (47.7) | 151 (53.7) | 152 (42.9) | 271 (42.7) | 117 (41.6) | 154 (43.5) | |||
| There is a test to determine if a person has HIV/AIDS | Correct | 557 (87.7) | 246 (87.5) | 311 (87.9) | 0.01 (0.91) | 545 (85.8) | 256 (91.1) | 289 (81.6) | 11.54 (< 0.001) |
| Incorrect | 78 (12.3) | 35 (12.5) | 43 (12.2) | 90 (14.2) | 25 (8.9) | 65 (18.4) | |||
| Anyone can become infected with HIV/AIDS | Correct | 454 (71.5) | 198 (70.5) | 256 (72.3) | 0.26 (0.61) | 493 (77.6) | 230 (81.9) | 263 (74.3) | 5.15 (< 0.05) |
| Incorrect | 181 (28.5) | 83 (29.5) | 98 (72.3) | 142 (22.4) | 51 (18.1) | 91 (25.7) | |||
| People can lower their chance of becoming infected with HIV by | |||||||||
| Not having sexual intercourse with anyone | Correct | 427 (67.2) | 192 (68.3) | 235 (66.4) | 0.27 (0.60) | 414 (65.2) | 190 (67.6) | 224 (63.3) | 1.30 (0.25) |
| Incorrect | 208 (32.8) | 89 (31.7) | 119 (33.6) | 221 (34.8) | 91 (32.4) | 130 (36.7) | |||
| Using condoms | Correct | 400 (63.0) | 184 (65.5) | 216 (61.0) | 1.34 (0.25) | 425 (66.9) | 210 (74.7) | 215 (60.7) | 13.86 (< 0.001) |
| Incorrect | 235 (37.0) | 97 (34.5) | 138 (39.0) | 210 (33.1) | 71 (25.3) | 139 (39.3) | |||
| Having sexual intercourse with only one partner, who is not infected with HIV/AIDS | Correct | 369 (58.1) | 161 (57.3) | 208 (58.8) | 0.14 (0.71) | 382 (60.2) | 185 (65.8) | 197 (55.7) | 6.78 (< 0.01) |
| Incorrect | 266 (41.9) | 120 (42.7) | 146 (41.2) | 253 (39.8) | 96 (34.2) | 157 (44.3) | |||
| CD4 count testing measures how many soldier cells we have in our blood that fight HIV | Correct | 524 (82.5) | 226 (80.4) | 298 (84.2) | 1.5 (0.22) | 515 (81.1) | 245 (87.2) | 270 (76.3) | 12.18 (< 0.001) |
| Incorrect | 111 (17.5) | 55 (19.6) | 56 (15.8) | 120 (18.9) | 36 (12.8) | 84 (23.7) | |||
| When a person is feeling healthy or their CD4 count is high it is okay for them to stop taking their medication | Correct | 390 (61.4) | 155 (55.2) | 235 (66.4) | 8.3 (< 0.01) | 374 (58.9) | 171 (60.9) | 203 (57.3) | 0.78 (0.37) |
| Incorrect | 245 (38.6) | 126 (44.8) | 119 (33.6) | 261 (41.1) | 110 (39.1) | 151 (42.7) | |||
| When a person’s CD4 count drops he/she has fewer soldier cells to fight infections | Correct | 373 (58.7) | 165 (58.7) | 208 (58.8) | < 0.001 (0.99) | 358 (56.5) | 190 (67.6) | 168 (47.6) | 25.52 (< 0.001) |
| Incorrect | 262 (41.3) | 116 (58.7) | 146 (41.2) | 276 (43.5) | 91 (32.4) | 185 (52.4) | |||
| Viral load tests measure how much HIV is in the blood | Correct | 454 (71.5) | 197 (70.1) | 257 (72.6) | 0.48 (0.49) | 425 (66.9) | 209 (74.4) | 216 (61.0) | 12.63 (< 0.001) |
| Incorrect | 181 (28.5) | 84 (29.9) | 97 (27.4) | 210 (33.1) | 72 (25.6) | 138 (39.0) | |||
| If the viral load is “undetectable”, this means there is no virus left in the body | Correct | 210 (33.1) | 80 (28.5) | 130 (36.7) | 4.8 (< 0.05) | 208 (32.8) | 90 (32.0) | 118 (33.3) | 0.12 (0.73) |
| Incorrect | 425 (66.9) | 201 (71.5) | 224 (63.3) | 427 (67.2) | 191 (68.0) | 236 (66.7) | |||
| If we say that the virus is “resistant” to a particular medicine that means that the medicine no longer works to lower or slow down the virus | Correct | 322 (50.7) | 152 (54.1) | 170 (48.0) | 2.3 (0.13) | 353 (55.6) | 190 (67.6) | 163 (46.1) | 29.52 (< 0.001) |
| Incorrect | 313 (49.3) | 129 (45.9) | 184 (52.0) | 282 (44.4) | 91 (32.4) | 191 (53.9) | |||
| The virus can become resistant if medication doses are missed | Correct | 433 (68.2) | 193 (68.7) | 240 (67.8) | 0.06 (0.81) | 421 (66.3) | 227 (80.8) | 194 (54.8) | 47.32 (< 0.001) |
| Incorrect | 202 (31.8) | 88 (31.3) | 114 (32.2) | 214 (33.7) | 54 (19.2) | 160 (45.2) | |||
| HIV can be passed from mother to child | Correct | 509 (80.2) | 224 (79.7) | 285 (80.5) | 0.06 (0.80) | 542 (85.4) | 236 (84.0) | 306 (86.4) | 0.76 (0.39) |
| Incorrect | 126 (19.8) | 57 (20.3) | 69 (19.5) | 93 (14.6) | 45 (16.0) | 48 (13.6) | |||
| Total HIV/AIDS knowledge score | [Range], mean (SD) | [24–49], 38.5 (4.7) | 38.1 (4.6) | 38.7 (4.7) | − 1.61 (0.12) | [25–48], 38.3 (4.5) | 39.3 (4.3) | 37.6 (4.5) | 4.73 (< 0.001) |
Incorrect responses included unsure and the incorrect response, Bold means statistically significant
Assessment of HIV Prevention Attitudes
Participants’ attitudes towards prevention was assessed at 12-months follow-up. They were asked to rate their agreement with five statements related to HIV prevention (see Table 2 for list of items included in this scale), with Agree a great deal = 5 to Not at all agree = 1.
Table 2.
Description of ALWHIV’s HIV prevention attitudes assessment at baseline and 12 months follow-up
| Baseline | 12 months | |||||||
|---|---|---|---|---|---|---|---|---|
| Total sample | Males | Females | t-test (P) | Total sample | Males | Females | t-test (P) | |
| HIV prevention attitudes assessment | N = 635 Mean (SD) | N = 281 Mean (SD) | N = 354 Mean (SD) | N = 635 Mean (SD) | N = 281 Mean (SD) | N = 354 Mean (SD) | ||
| As a teenager I think AIDS is a threat to my health | 3.9 (1.5) | 4.1 (1.4) | 3.8 (1.5) | 2.4 (< 0.05) | 4.0 (1.5) | 4.1 (1.5) | 3.9 (1.4) | 1.4 (0.18) |
| I think all people my age who have sex should use condoms | 3.2 (1.7) | 3.3 (1.7) | 3.3 (1.7) | 0.6 (0.55) | 3.7 (1.6) | 3.9 (1.5) | 3.5 (1.6) | 3.0 (< 0.01) |
| I think the best way to avoid getting AIDS is not to have sex | 3.6 (1.6) | 3.6 (1.6) | 3.5 (1.6) | 0.7 (0.50) | 3.8 (1.5) | 4.0 (1.4) | 3.6 (1.6) | 3.2 (< 0.01) |
| Even if you know your partner very well you should use a condom | 3.4 (1.7) | 3.5 (1.7) | 3.2 (1.7) | 2.3 (< 0.05) | 3.7 (1.5) | 3.9 (1.5) | 3.5 (1.6) | 2.9 (< 0.01) |
| I think it is very important to use condoms every time one has sex | 3.5 (1.7) | 3.5 (1.7) | 3.4 (1.7) | 0.8 (0.41) | 3.8 (1.5) | 3.9 (1.4) | 3.7 (1.5) | 1.8 (0.07) |
| Total HIV prevention attitudes score: Range [5–25] | 17.6 (6.2) | 18.1 (6.1) | 17.3 (6.2) | 1.8 (0.07) | 18.9 (5.6) | 19.8 (5.3) | 18.3 (5.7) | 3.4 (< 0.001) |
Measures of Mental Health Functioning
We utilized three indicators of mental health functioning (hopelessness, depression, and self-concept), as the main independent variables, to better understand how they affect ALWHIV’s HIV knowledge and HIV prevention attitudes at 12-month follow-up. These measures have been tested, validated, and adapted for cultural appropriateness among children and adolescents in Uganda [23–26].
Hopelessness
The Beck Hopelessness scale includes 20 items and assesses the extent of an individual’s pessimism and negative expectations about the future [27]. Each item is answered as true or false. Items in the inverse direction were reverse coded. All items were summed, with higher scores representing greater levels of hopelessness. Hopelessness, is a key characteristic of depression and also carries an elevated suicide risk [28]. The sample range was 0–16, with an acceptable Cronbach’s alpha of 0.72 at baseline.
Depressive Symptoms
Depressive symptoms were assessed using the Children’s Depression Inventory (CDI), which is one of the most widely utilized standardized self-report instruments for assessing depressive symptoms among children and has proven successful in several different cultural contexts [29–31]. The 14 items of the CDI used in the current study were adapted from the original 28-items long version scale, which measures both emotional and functional problems that correspond with depression in children. The 14-item scale has previously been used in Uganda [32]. Each item on the CDI has three response options that correspond to varying levels of symptomology for clinical depression [33]. Items were coded and summed with higher scores indicating higher levels of depressive symptoms. The sample range was 0–20, with a Cronbach’s alpha of 0.64 at baseline.
Self-Concept
We used 18 items adapted from the original 100-item of Tennessee Self Concept Scale (TSCS) to measure children’s self-concept or how they see themselves as a person [34]. Responses were given on Likert scales, ranging from 1 = always false to 5 = always true. Inverse items were reverse coded. We created a summated total score with higher scores indicating higher levels of self-concept. Scores ranged from 43 to 85 in this sample, with an acceptable Cronbach’s alpha of 0.76 at baseline.
Covariates
In addition to the main independent variables, we adjusted for baseline sociodemographic covariates including age, gender (female vs. male), type of primary caregiver (parents vs. grandparents vs. other relatives), number of children in the household, number of people in the household, and Suubi + Adherence intervention group assignment. In addition, we adjusted for family assets that was measured using a 20-item index, which assessed the ownership of tangible household assets (e.g., house, livestock, garden, and transportation). Specifically, participants were asked, “Does the family you live with own the following? House, land, bicycle etc.” Those owning less than seven assets were considered as having low possession while seven or more as high possession [35]. Those owning less than seven assets were considered as having low possession while seven or more as high possession.
Statistical Analysis
We conducted ordinary least square regression (OLS) to evaluate the association between the three indicators of mental health functioning and ALWHIV’s HIV knowledge and prevention attitudes at 12-months follow-up. Standard errors were adjusted for clustering by clinics. Beta coefficients and 95% confidence intervals of the predictor effects were derived. All analyses were conducted in Stata Version 15.1.
Results
Description of Study Population
Participants were aged 10–16 at baseline with an average age of 12.3 years (Table 3). Females comprised 56% of the sample. At 12-months follow-up (N = 635), ALWHIV in Uganda knowledge about HIV scores ranged from 25 to 48. The mean (SD) knowledge score was 38.3 (4.5), indicating average knowledge about HIV among the sample. HIV prevention attitudes scores ranged from 5 to 25, with a mean (SD) score of 18.9 (5.6) at 12-months follow-up. On average, there were no significant differences between males and females, respectively on HIV prevention attitudes (18.1 vs. 17.3, t = 1.8; p = 0.07) and HIV knowledge (38.1 vs. 38.7, t = − 1.61; p = 0.12) at baseline. However, at 12-month follow-up, males were on average more likely to report higher scores on HIV prevention attitudes (19.8 vs. 18.3, t = 3.4; p < 0.001) and HIV knowledge (39.3 vs. 37.6, t = 4.7; p < 0.001) compared to females.
Table 3.
Socio-demographic characteristics of study participants at baseline
| Sociodemographic characteristics | N = 635 |
|---|---|
| Age [range 10–16], mean (SD) | 12.3 (1.9) |
| Gender | |
| Males, n (%) | 281 (44.3) |
| Females, n (%) | 354 (55.8) |
| Number of people in household [range 2–18], mean (SD) | 5.8 (2.5) |
| Number of children in household [range 0–9], mean (SD) | 2.3 (1.8) |
| Primary caregiver | |
| Parents, n (%) | 305 (48.1) |
| Grandparents, n (%) | 188 (29.7) |
| Other relatives, n (%) | 141 (22.2) |
| Assets | |
| High possession, n (%) | 564 (88.2) |
| Low possession, n (%) | 71 (11.8) |
| Group assigned | |
| Control group, n (%) | 313 (49.3) |
| Intervention group, n (%) | 322 (50.7) |
SD standard deviation
Multiple Linear Regression Findings
HIV Prevention Attitudes
As presented in Table 4, depression, age and gender were significantly associated with HIV prevention attitudes at 12 months follow-up. In the adjusted model, every 1-unit increase in ALWHIV depression scores at baseline was associated with a 0.17 average reduction in HIV prevention attitudes scores at 12-months follow-up (β = − 0.17; 95% CI − 0.31, − 0.04). HIV Prevention attitudes scores were lower in females than males by an average of 1.91 (β = − 1.91; 95% CI − 2.65, − 1.16), suggesting that females had less favorable HIV prevention attitudes than males. Every 1-year increase in adolescents’ age, was associated with a 0.77 increase in HIV prevention attitudes scores indicating more favorable prevention attitudes as age increased (β = 0.77; 95% CI 0.51, 1.02).
Table 4.
Multiple linear regression results for HIV prevention attitudes and HIV knowledge among ALWHIV
| HIV prevention attitudes at 12 months follow-up | HIV knowledge at 12 months follow-up | |
|---|---|---|
| β (95% CI) | β (95% CI) | |
| Sociodemographic characteristics | ||
| Age | 0.77 (0.51, 1.02) *** | 0.92 (0.69, 1.15) *** |
| Gender | ||
| Males | Ref | Ref |
| Females | − 1.91 (− 2.65, − 1.16) *** | − 1.95 (− 2.78, − 1.12) *** |
| Number of children in household | − 0.11 (− 0.47, 0.25) | 0.13 (− 0.22, 0.48) |
| Number of people in household | 0.11 (− 0.15, 0.38) | − 0.07 (− 0.28, 0.13) |
| Primary caregiver | ||
| Parents | Ref | Ref |
| Grandparents | 0.19 (− 1.08, 1.46) | 0.03 (− 0.76, 0.82) |
| Other relatives | − 0.70 (− 1.85, 0.45) | − 0.55 (− 1.31, 0.21) |
| Assets | ||
| High possession | Ref | Ref |
| Low possession | − 0.11 (− 1.85, 1.63) | 1.20 (−0.15, 2.54) |
| Group assigned | ||
| Control group | Ref | Ref |
| Intervention group | − 0.11 (− 1.84, 1.63) | − 0.37 (− 1.29, 0.54) |
| Mental health indicators | ||
| Depression score | − 0.17 (− 0.31, −0.04) ** | − 0.04 (− 0.15, 0.08) |
| Hopelessness score | − 0.11 (− 0.25, 0.02) | − 0.16 (− 0.28, − 0.04) * |
| Self-concept score | 0.02 (− 0.05, 0.08) | 0.04 (− 0.01, 0.09) |
β = beta coefficients; 95% CI = 95% confidence intervals; Bolded numbers represent statistically significant results
ALWHIV adolescents living with HIV
p = 0.05;
p = 0.01;
p < 0.001
HIV Knowledge
For the outcome HIV knowledge (Table 4), after adjusting for social demographic factors, every 1-unit increase in hopelessness scores was associated with a 0.16 average reduction in HIV knowledge scores (β = − 0.16; 95% CI − 0.28, − 0.04). Similar to HIV prevention attitudes, female ALWHIV HIV knowledge scores were also lower than males by an average of 1.95 points (β = − 1.95; 95% CI − 2.78, − 1.12) Additionally, every 1-year increase in adolescents’ age, was associated with increase in knowledge scores (β = 0.92; 95% CI 0.69, 1.15). Self-concept was not significantly associated with HIV knowledge or prevention attitudes among ALWHIV.
Discussion
Given the limited literature on the impact of mental health on HIV prevention knowledge and attitudes among ALWHIV in low-resource settings, our study is of utmost importance in the efforts to end the HIV epidemic. The current study supports the negative impact of mental health on key predictors of behavioral health outcomes including adherence to treatment and risk reduction behaviors. We examined the effect of three indicators of mental health functioning (depression, hopelessness, and self-concept) on ALWHIV’s HIV prevention attitudes and knowledge. Our findings indicate that ALWHIV with higher depression scores, indicative of greater depressive symptomatology are at risk of having less favorable attitudes towards HIV prevention and transmission while ALWHIV with greater levels of hopelessness were at risk of being less knowledgeable about HIV and HIV transmission including knowledge on risk-behavior, prevention, stigma, medication adherence, viral load, and testing measures. Self-concept was not significantly associated with HIV knowledge or prevention attitudes. In addition to the main findings, older age was associated with greater knowledge and more favorable prevention attitudes and female adolescents had less favorable HIV prevention attitudes than males and were less knowledgeable about HIV than males.
Given that study participants were likely to be perinatally infected, and the fact that adolescents have to deal with a chronic and stigmatizing disease, they are more likely to experience depression and hopelessness because of managing the disease, as found in other studies [36, 37]. However, in Ugandan HIV clinics, general counseling is provided for all individuals receiving HIV care at health clinics including adolescents who participated in the Suubi + Adherence study [38]. Para counsellor and expert clients trained in counseling are available at the clinics to support clients. In addition, during the Suubi + Adherence study, referral protocols were developed in the event that participants with severe mental health problems were identified [20]. One explanation for the lower knowledge scores among ALWHIV with greater hopelessness could be that ALWHIV are likely to lose hope and motivation to not only maintain their antiretroviral treatment regimen but also attend counseling sessions on youth clinic days. Hence, they may be missing key information that is critical for prevention and building HIV/AIDS knowledge, which is often provided on youth clinic days and refill appointments [36, 37]. Alternatively, depression can get in the way of retaining knowledge and ALWHIV may have cognitive issues that may prevent them learning in the first place or it may be taught in ways that are not meaningful to youth. In many settings in SSA, mental health assessment is not provided and can go undetected and untreated for longer periods in many patients. Altogether, this may make it difficult for ALWHIV to learn and retain knowledge regarding HIV prevention and transmission, which is critical to avert vertical infections among ALWHIV.
In addition to girls more likely to report depression, our finding on female ALWHV having lower HIV knowledge and less favorable prevention attitudes than males supports the fact that adolescent girls and young women carry an even greater HIV burden in SSA, with almost two out of three daily infections occurring among females [1]. Although our sample comprised adolescents living with perinatally-acquired infection, several factors make adolescent girls vulnerable to HIV infection in Uganda and other SSA countries including lack of access to education due to household economic instability [39], often cited as the main reason why adolescent girls fail to attend school [40, 41]. Similarly, when there are fewer family resources, male education is prioritized over female education due to gendered and stratified roles, which encourage adolescent marriage and child bearing and does not question male authority [42, 43]. For female ALWHIV, this is likely to be a double tragedy especially if they have lost parents and have to live with other caregivers. For adolescent girls living with perinatally-acquired infections, limited knowledge on HIV transmission puts them at a risk for HIV transmission to uninfected partners, re-infection, as well as vertical transmission of HIV [44].
According to the Ugandan Ministry of Health [45], adolescents are considered as having comprehensive HIV knowledge if: they correctly identify the two major ways of preventing the sexual transmission of HIV (using condoms and limiting sex to one faithful, uninfected partner). In addition, they are required to reject the two most common local misconceptions about HIV transmission (through mosquito bites and sharing food or utensils with an infected person); and know that a healthy-looking person can transmit HIV. Consistent with these guidelines, in our study, at 12 months more ALWHIV were able to correctly identify condom use (correct n = 425, 66.9%; incorrect n = 210, 33.1%) and being faithful (correct n = 382, 60.2%; incorrect n = 253, 39.8%) as the ways to prevent HIV. That said, at least 1/3-almost 40% had incorrect responses. Moreover, over half of ALWHIV thought that a mosquito bite would transmit HIV (n = 354, 55.8%) and the majority of ALWHIV wrongly selected two common local myths regarding HIV transmission, specifically, touching toilet seats, spoons, cups, or other objects after a person infected with HIV/AIDS was identified as unsafe (correct n = 267, 42.1%; incorrect n = 368, 58.0%) and you can look at a person and tell if they are infected with HIV/AIDS (correct n = 273, 43%; incorrect n = 362, 57%). This highlights the need for interventions to address misconceptions and HIV-related stigma even among ALWHIV who may internalize these myths and feel discriminated, isolated, and hopeless [46].
These findings show that most ALWHIV who experience hopelessness are at risk for re-infection and transmission of HIV to others, which may partly be due to their limited knowledge on HIV, and transmission risks. Interventions that address hopelessness and targeted HIV educational interventions, particularly for adolescent girls could help improve ALWHIV knowledge that may translate into safer behaviors and contribute to alleviating the burden of HIV among adolescents in SSA. Some of the successful interventions with potential for scale up include the VUKA and CHAMP programs in South Africa [47, 48]. The VUKA/CHAMP + program addresses mental health, adherence and sexual risk reduction among adolescents living with HIV including sessions on knowledge about how the virus works and has been examined in South Africa, Thailand and the United States [49–52].
In low-resource settings it has been recommended that mental health care be integrated into HIV care given limited resources. This might be one way to address the threats to knowledge and attitudes found in this study including the negative impact of mental health. Since depression is one of the most common mental disorders among HIV positive people in SSA [53], for ALWHIV with poor prevention attitudes this may translate in poor health decisions and consequently poor health-related outcomes including high risk sexual activity, poor adherence, and HIV transmission [54]. Reduction of depressive symptoms, treatment for depression and prevention of relapse among ALWHIV should thus be a priority. Since improved knowledge and more favorable prevention attitudes increased with age, younger adolescents may benefit from HIV prevention and educational resources designed for communication to younger teens.
Strengths and Limitations
We used longitudinal data from ALWHIV in Uganda to examine the association between three mental health indicators at baseline, on ALWHIV attitudes towards prevention and knowledge about HIV 12 months later ensuring chronological order and examined the long-term effects of mental health functioning on HIV and AIDS knowledge and prevention attitudes. The broad selection criteria for study participation in the Suubi + Adherence study allows findings from this sample to be easily generalized to other ALWHIV populations in SSA. However, we acknowledge that having correct knowledge and favorable attitudes may not translate into actual behavior. Although having the correct knowledge regarding myths could avoid unnecessary feelings of stigma and discrimination occurring among ALWHIV.
Conclusion
ALWHIV with greater levels of hopelessness are at increased risk of having limited HIV knowledge while ALWHIV with greater symptoms of depression are likely to have less favorable HIV prevention attitudes. Furthermore, younger adolescents and female ALWHIV are in greater need of interventions to improve their education about HIV and to support more positive attitudes towards prevention behaviors than males and older youth. Improving both knowledge and attitudes among ALWHIV has the potential to improve health outcomes in this population and minimize the spread of HIV to others, contributing to efforts to end the HIV epidemic.
Acknowledgements
Suubi+Adherence study was funded by the Eunice Kennedy Shriver National Institutes of Child Health and Human Development (NICHD) (Grant #1R01HD074949-01, PI: Fred M. Ssewamala). The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Footnotes
Conflict of interest The authors have no conflict of interest to declare that are relevant to the content of this article.
Ethical Approval and Informed Consent Adolescents provided voluntary written assent and caregivers provided consent for the adolescent to participate in the study. The recruitment and interaction with human subjects and their health information were completed according to protocols reviewed and approved by Columbia University (Protocol AAAK3852), the Makerere University School of Public Health (Protocol 210) and the Uganda National Council for Science and Technology (Protocol SS 2969) Ethics and Institutional Review Boards.
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