Early initiation of anti-retroviral treatment (ART) for HIV-infected persons has enormous benefits, including decreased morbidity and mortality, and reduced secondary transmission. In South Africa, the high mortality rates seen early in ART programs are often due to advanced disease stage at care initiation. The South African government has prioritized widespread HIV testing since 2010 but this campaign will not improve clinical and preventive outcomes unless HIV-infected persons engage in care in a timely manner. In sub-Saharan Africa, the prevalence of HIV infection is extremely high in adolescent women. Treatment and prevention of HIV in this population is critical to reduce the burden of disease. However, challenges to engagement in care, such as perceived stigma and non-adherence to care and treatment, are likely magnified in HIV-infected adolescents. In adults in South Africa, pre-ART loss to care is as high as 50%, and may be even greater in adolescents. To improve the link between HIV testing and treatment among young women, modifiable barriers that might preclude accessing of clinical services must be understood. Psychosocial and behavioral factors affect adherence to care and treatment among HIV-infected persons, and may be especially important for adolescents because their psychological, social, and physical contexts are undergoing change. HIV-infected adolescents are at increased risk of mental health illnesses and behavioral disorders, but these factors have not been studied in the context of engagement in care. The objective of this Kirschstein-NRSA individual fellowship (F30) is to assess modifiable psychosocial barriers to engagement in care among HIV- infected adolescent women in rural South Africa. The proposed study will be a one-year prospective cohort design among newly diagnosed HIV-infected young women incorporated into an ongoing randomized controlled trial, with the following specific aims: 1) To evaluate the relationship between disclosure of HIV infection status and engagement in care over 1 year following diagnosis;2) To determine the relationship between baseline and incident depression and anxiety disorders and engagement in care;and 3) To determine the relationship between coping responses to newly diagnosed HIV and engagement in care. This study will be the first to evaluate modifiable personal factors that may affect health-care utilization among HIV-infected adolescent women in sub-Saharan Africa. Findings from the proposed research will inform future interventions to improve engagement in care specific to this vulnerable and high-risk population. This F30 fellowship will provide the applicant with exceptional integrated training in epidemiology, HIV, infectious diseases, and mental health to further her career goals as a physician-epidemiologist studying HIV infection and sexually transmitted diseases in resource-scarce settings.

Public Health Relevance

Early engagement in care among HIV-infected persons is a critical component of successful HIV treatment and prevention programs, yet up to 50% of HIV-infected South Africans do not seek care until they are clinically ill. The proposed study will be the first to assess modifiable psychosocial barriers to engagement in care among HIV-infected young South African women, a group at particularly high risk for HIV infection. Results from this work will inform future interventions to improve engagement in care that are specifically targeted to this vulnerable population.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Individual Predoctoral NRSA for M.D./Ph.D. Fellowships (ADAMHA) (F30)
Project #
Application #
Study Section
Special Emphasis Panel (ZRG1-AARR-J (22))
Program Officer
Stoff, David M
Project Start
Project End
Budget Start
Budget End
Support Year
Fiscal Year
Total Cost
Indirect Cost
University of North Carolina Chapel Hill
Public Health & Prev Medicine
Schools of Public Health
Chapel Hill
United States
Zip Code
Levis, Brooke; Benedetti, Andrea; Riehm, Kira E et al. (2018) Probability of major depression diagnostic classification using semi-structured versus fully structured diagnostic interviews. Br J Psychiatry 212:377-385
Cholera, Rushina; Pence, Brian W; Bengtson, Angela M et al. (2017) Mind the Gap: Gaps in Antidepressant Treatment, Treatment Adjustments, and Outcomes among Patients in Routine HIV Care in a Multisite U.S. Clinical Cohort. PLoS One 12:e0166435
Sowa, Nathaniel A; Cholera, Rushina; Pence, Brian W et al. (2015) Perinatal depression in HIV-infected African women: a systematic review. J Clin Psychiatry 76:1385-96
Cholera, R; Gaynes, B N; Pence, B W et al. (2014) Validity of the Patient Health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa. J Affect Disord 167:160-6