Browsing by Author "Toska, Elona"
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- ItemOpen AccessAccess to Tuberculosis testing among adolescents living with Human Immunodeficiency Virus in the Eastern Cape, South Africa: social factors and theoretical considerations(2022) van Staden, Quintin; Toska, Elona; Garba, Muhammed FaisalBackground: Addressing adolescent tuberculosis (TB) is a critical step towards eliminating TB in high burden countries, especially in HIV endemic communities. South Africa has the highest rates of TB/HIV co-infection and the largest population of adolescents living with HIV (ALHIV) in the world – contributing substantial risk to TB-related morbidity and mortality in this already vulnerable cohort. Previous research on TB has largely overlooked adolescents and ALHIV which has left knowledge – and potential service provision – gaps, but also opportunities for important research. TB among ALHIV is a complex public health challenge, needing to be understood in the context of the unique socio-emotional life stage of adolescence. This dissertation aims to provide insights into the critical first step in the ALHIV TB care cascade: access to TB testing. Through quantitative analysis, I explore the social factors that promote or prevent ALHIV from accessing TB testing in South Africa. Methods: In this longitudinal study, I analysed the Mzantsi Wakho cohort data from n=1046 ALHIV (10-19 years old) from 53 health facilities across the Amathole district of the Eastern Cape. N= 933 (89%) ALHIV – those who participated in the second and third cohort waves – were included in this analysis. Data were collected through self-reported questionnaires, assisted by trained and experienced researchers three times between 2014/2015 to 2017/2018. The selection of social factors that influence access to the outcome of TB testing was informed by an extensive scoping literature review. These factors were initially categorised using WHO's social determinants of health framework, which applies the Ecological Model. Thereafter, factors were filtered through the People Centred Model of TB care – to draw focus to the factors pertaining to the individual (both inter- and intrapersonal) rather than factors imbedded in health systems and services. Analysis was conducted in four steps: First descriptive analyses was used to summarise sociodemographic characteristics, relevant TB clinical data and HIV related factors at each interview (T2 and T3). Secondly, cross tabulation and frequencies of factors were done, comparing ALHIV who tested for TB to those that did not. Thirdly, univariate analysis was performed to identify factors with statistically significant associations with having a TB test or not. Lastly, multivariate regression models of these significant factors were run, both for each time point and over time (across both time points) using a stepwise approach by Hosmer-Lemeshow. The “why” or “how” these specific factors affected the probability of TB testing were then explored through the application of sociological theories and concepts, including the life course approach, social action theory and habitus. Findings: Consistently experiencing the following factors over time were linked to greater odds of TB testing: being 15 years and older (OR 1.43, CI 1.06-1.92, p 0.019), female ALHIV (OR 1.34, CI 1.02-1.75, p 0.033), in a relationship at both time points (OR 1.79, CI 1.23-2.62, p 0.002) and having had a viral load test each year (OR 1.50, CI 1.11-2.02, p 0.008). Having TB symptoms at either wave 2 or 3 was associated with TB testing (OR 1.46, CI 1.08-1.96, p 0.013). At Wave 2, no sim card phone (OR 0.64, CI 0.47-0.85, p 0.002) and having to pay R10 or more to get to the clinic (OR 0.68, CI 0.51-0.92, p 0.011) were associated with lower odds of TB testing, while viral load testing in the past year (OR 1.74, CI 1.26-2.40, p 0.001), living in a rural setting (0R 1.54, CI 1.10-2.16, p 0.012), being 15 years and older (OR 1.60, CI 1.19- 2.15, p 0.002) and reporting any TB symptoms (OR 1.72, CI 1.29-2.30, p< 0.001) were associated with higher odds of TB testing. At Wave 3, when most of the participants were in late adolescence being 15 years and older (OR 1.61, CI 1.19-2.19, p 0.002), living in informal housing (OR 1.58, CI 1.07-2.37, p 0.023), being in a relationship (OR 1.58, CI 1.15-2.18, p.005), experienced community violence (OR 1.43, CI 1.05-1.96, p 0.023), food security (OR 1.53, CI 1.11-2.11, p 0.010) and experienced any TB symptoms (OR 1.65, CI 1.25-2.20, p 0.001) had higher odds of reporting TB testing. Discussion and Conclusion: In this Eastern Cape cohort of ALHIV, factors linked to where ALHIV live (living rurally, cost to get the clinic more than R10, living in informal housing and having experienced community violence) as a reflection of the deep structural issues that shape health symptoms and healthcare access, who they are (age, sex) and their close emotional and nutritional support (being in a relationship, food security) have shown to strongly influence TB testing. Some of these factors are directly linked to increasing risk of TB exposure or vulnerability to TB: rural residence, informal housing and unsafe communities. To delve into why these factors shaped TB testing in ALHIV, sociological theories and concepts were applied to these findings. This dissertation took a holistic approach to bridge a critical knowledge gap in ALHIV's entry into TB care, extending our biomedical understanding with applied sociological frameworks. The work of this dissertation could enhance the current HIV services package offered to ALHIV by creating an awareness and identifying adolescents that may not be reached by current TB testing services. With this insight, TB services in South Africa, and perhaps broader afield, can introduce targeted interventions and social protection measures tailored to address adolescent TB testing, particularly in terms of integrating TB testing into HIV services.
- ItemOpen AccessExperiences and social determinants of sexual violence and post-violence help-seeking behaviour among children and young people in Kenya(2023) Okova, Denis; Toska, Elona; Bounagnin, Bolade; Alaba, OlufunkeThis dissertation examined the social determinants of sexual violence experience and help- seeking among Kenyan young men and women. Sexual violence is a public health concern because its levels are unacceptably high in Kenya, and it is a known risk factor for HIV infection.This is an urgent issue because Kenya has the third-largest HIV epidemic in the world and almosthalf of new HIV infections occur among young people. Therefore, preventing sexual violence is only possible if predictors of sexual violence and response pathways are continuously investigated. This study used Kenya's 2019 Nationally Representative Violence against Children Survey (VACS) data focusing on young men and women aged 13-24 years old. Sexual violence was defined as reporting unwanted touching, forced sex, attempted forced sex, or experiencing physical forced sex/rape, either in one's lifetime or in the past year both of which were binary variables. Help-seeking behavior was indicated by knowing where to seek formal help, seeking formal help, receiving formal help, and informal disclosure all of which are binary variables. This study first documents the pathway of sexual violence from exposure to help-seeking among young men and women in Kenya. Logistic regression models were then fitted to investigate predictors of sexual violence experience over the past year and lifetime disclosure of sexual violence in young women, controlling for age, being in a relationship, education status, HIV/AIDS testing, orphanhood, and household poverty. This study had 1344 female and 788 male participants. Young women reported a higher lifetime prevalence of sexual violence compared with young men (25.2% vs. 11.4%, p=0.000). Of these lifetime experiences of sexual violence, more young women than young men informally disclosedthese acts (45.1% vs. 22.7%, p=0.002). Although 33.7% of young women and 33.1% of young men knew where to seek formal help after experiencing sexual violence, more young women thanyoung men sought formal help after experiencing sexual violence (11.3% vs 6.8%, p=0.248). Gender inequitable attitudes [AOR 3.07 (1.10–8.56); p=0.032], experiencing emotional violence at home [AOR 2.11 (1.17–3.81); p=0.014], and cyberbullying [AOR 5.90 (2.83–12.29);p=0.000] are risk factors for sexual violence among young women. Life skills training [AOR 0.22 v (0.07– 0.73); p=0.014] and positive parental monitoring [AOR 0.31 (0.10–0.99);p=0.048] are protective against sexual violence among young women. Positive parental monitoring [AOR 3.85 (1.56– 9.46);p=0.004] was also associated with increased likelihood of informal disclosure among young women. This study highlights the protective value of life skills training and positive parental monitoring in sexual violence prevention. Moreover, this analysis demonstrated the possible role of gender inequitable attitudes, cyberbullying, and emotional violence at home in fueling sexual violence. Future VACS might consider increasing sample sizes to increase robustness of analyses, especially on help-seeking.
- ItemOpen AccessExploring the mental health experiences of young mothers affected by HIV in South Africa(2024) Busakhwe, Chuma; Toska, ElonaThe mental health of young women living in adversity, including those at risk of HIV exposure and early pregnancy, remains understudied. This study contributed to this research gap by exploring the mental health experiences of young mothers affected by HIV in South Africa. Seventeen semi-structured interviews were conducted with 18-24-year-old young mothers in the Eastern Cape, South Africa, twelve of whom were living with HIV. Interviews were recorded, transcribed, and analysed using thematic approaches. The study found that psychological research's framing of mental health does not always align with young mothers' understanding and articulation of their day-to-day experiences of their wellbeing. Furthermore, young mothers experienced multiple stressors and challenges which affected their mental health, including school disruptions, coming to terms with their HIV status and unintended pregnancy, and experiences of violence. Adjusting to their new realities and transitioning into their roles as mothers was overwhelming as they were not prepared for such sudden changes in their lives. Additionally, young mothers living with HIV are more vulnerable to poor mental health experiences, particularly at the intersection of early motherhood and HIV syndemic. Young mothers living with HIV employed different techniques to negotiate and navigate living with HIV. The majority experienced profound levels of HIV stigma within their social environments. As a result, young mothers chose not to disclose their HIV status due to fear of being exposed to further discrimination and rejection. To design supportive interventions, research must understand young mothers' emotional challenges and mental health experiences over time including different life stages from pregnancy to motherhood, because their mental health burden is affected by exposure to multiple overlapping or simultaneous stressors. Key words: mental health, HIV, young women, early motherhood, syndemic, stigma and South Africa
- ItemOpen AccessThe HIV care cascade for adolescents initiated on antiretroviral therapy in a health district of South Africa: a retrospective cohort study(2021-01-13) Haghighat, Roxanna; Toska, Elona; Bungane, Nontuthuzelo; Cluver, LucieBackground Little evidence exists to comprehensively estimate adolescent viral suppression after initiation on antiretroviral therapy in sub-Saharan Africa. This study examines adolescent progression along the HIV care cascade to viral suppression for adolescents initiated on antiretroviral therapy in South Africa. Methods All adolescents ever initiated on antiretroviral therapy (n=1080) by 2015 in a health district of the Eastern Cape, South Africa, were interviewed in 2014–2015. Clinical records were extracted from 52 healthcare facilities through January 2018 (including records in multiple facilities). Mortality and loss to follow-up rates were corrected for transfers. Predictors of progression through the HIV care cascade were tested using sequential multivariable logistic regressions. Predicted probabilities for the effects of significant predictors were estimated by sex and mode of infection. Results Corrected mortality and loss to follow-up rates were 3.3 and 16.9%, respectively. Among adolescents with clinical records, 92.3% had ≥1 viral load, but only 51.1% of viral loads were from the past 12 months. Adolescents on ART for ≥2 years (AOR 3.42 [95%CI 2.14–5.47], p< 0.001) and who experienced decentralised care (AOR 1.39 [95%CI 1.06–1.83], p=0.018) were more likely to have a recent viral load. The average effect of decentralised care on recent viral load was greater for female (AOR 2.39 [95%CI 1.29–4.43], p=0.006) and sexually infected adolescents (AOR 3.48 [95%CI 1.04–11.65], p=0.043). Of the total cohort, 47.5% were recorded as fully virally suppressed at most recent test. Only 23.2% were recorded as fully virally suppressed within the past 12 months. Younger adolescents (AOR 1.39 [95%CI 1.06–1.82], p=0.017) and those on ART for ≥2 years (AOR 1.70 [95%CI 1.12–2.58], p=0.013) were more likely to be fully viral suppressed. Conclusions Viral load recording and viral suppression rates remain low for ART-initiated adolescents in South Africa. Improved outcomes for this population require stronger engagement in care and viral load monitoring.
- ItemRestricted'HIV is like a tsotsi. ARVs are your guns': associations between HIV-disclosure and adherence to antiretroviral treatment among adolescents in South Africa(International AIDS Society, 2015) Cluver, Lucie D; Hodes, Rebecca J; Toska, Elona; Kidiad, Khameer K; Orkina, Mark F; Sherrf, Lorraine; Meincka, FranziskaObjectives: WHO guidelines recommend disclosure to HIV-positive children by school age in order to improve antiretroviral therapy (ART) adherence. However, quantitative evidence remains limited for adolescents. This study examines associations between adolescent knowledge of HIV-positive status and ART-adherence in South Africa. Design: A cross-sectional study of the largest known community-traced sample of HIVpositive adolescents. Six hundred and eighty-four ART-initiated adolescents aged 10–19 years (52% female, 79% perinatally infected) were interviewed. Methods: In a low-resource health district, all adolescents who had ever initiated ART in a stratified sample of 39 health facilities were identified and traced to 150 communities [n ¼ 1102, 351 excluded, 27 deceased, 40 (5.5%) refusals]. Quantitative interviews used standardized questionnaires and clinic records. Quantitative analyses used multivariate logistic regressions, and qualitative analyses used grounded theory for 18 months of interviews, focus groups and participant observations with 64 adolescents, caregivers and healthcare workers. Results: About 36% of adolescents reported past-week ART nonadherence, and 70% of adolescents knew their status. Adherence was associated with fewer opportunistic infection symptoms [odds ratio (OR) 0.55; 95% CI 0.40–0.76]. Adolescent knowledge of HIV-positive status was associated with higher adherence, independently of all cofactors (OR 2.18; 95% CI 1.47–3.24). Among perinatally infected adolescents who knew their status (n ¼ 362/540), disclosure prior to age 12 was associated with higher adherence (OR 2.65; 95% CI 1.34–5.22). Qualitative findings suggested that disclosure was undertaken sensitively in clinical and family settings, but that adults lacked awareness about adolescent understandings of HIV status. Conclusion: Early and full disclosure is strongly associated with improved adherence amongst ART-initiated adolescents. Disclosure may be an essential tool in improving adolescent adherence and reducing mortality and onwards transmission.
- ItemOpen AccessScreening and supporting through schools: educational experiences and needs of adolescents living with HIV in a South African cohort(BioMed Central, 2019-03-06) Toska, Elona; Cluver, Lucie; Orkin, Mark; Bains, Anurita; Sherr, Lorraine; Berezin, McKenzie; Gulaid, LaurieBackground Many adolescents living with HIV remain disconnected from care, especially in high-prevalence settings. Slow progressors–adolescents infected perinatally who survive without access to lifesaving treatment–remain unidentified and disconnected from heath systems, especially in high-prevalence settings. This study examines differences in educational outcomes for ALHIV, in order to i) identify educational markers for targeting HIV testing, counselling and linkages to care, and ii) to identify essential foci of educational support for ALHIV. Methods Quantitative interviews with N = 1063 adolescents living with HIV and N = 456 HIV-free community control adolescents (10–19 year olds) included educational experiences (enrolment, fee-free school, school feeding schemes, absenteeism, achievement), physical health, cognitive difficulties, mental health challenges (depression, stigma, and trauma), missing school to attend clinic appointments, and socio-demographic characteristics. Voluntary informed consent was obtained from adolescents and caregivers (when adolescent < 18 years old). Analyses included multivariate logistic regressions, controlling for socio-demographic covariates, and structural equation modelling using STATA15. Results ALHIV reported accessing educational services (enrolment, free schools, school feeding schemes) at the same rates as other adolescents (94, 30, and 92% respectively), suggesting that school is a valuable site for identification. Living with HIV was associated with poorer attendance (aOR = 1.7 95%CI1.1–2.6) and educational delay (aOR1.7 95%CI1.3–2.2). Adolescents who reported educational delay were more likely to be older, male, chronically sick and report more cognitive difficulties. A path model with excellent model fit (RMSEA = 0.027, CFI 0.984, TLI 0.952) indicated that living with HIV was associated with a series of poor physical, mental and cognitive health issues which led to worse educational experiences. Conclusion Schools may provide an important opportunity to identify unreached adolescents living with HIV and link them into care, focusing on adolescents with poor attendance, frequent sickness, low mood and slow learning. Key school-based markers for identifying unreached adolescents living with HIV may be low attendance, frequent sickness, low mood and slow learning. Improved linkages to care for adolescents living with HIV, in particular educational support services, are necessary to support scholastic achievement and long-term well-being, by helping them to cope with physical, emotional and cognitive difficulties.