Prevalence and Factors Associated with Emotional Problems Among HIV-Positive Children and Adolescents with Viral Non-Suppression in Rural Northern Uganda.

Prevalence and Factors Associated with Emotional Problems Among HIV-Positive Children and Adolescents with Viral Non-Suppression in Rural Northern Uganda. | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Prevalence and Factors Associated with Emotional Problems Among HIV-Positive Children and Adolescents with Viral Non-Suppression in Rural Northern Uganda. Jeremiah Kwesiga Mutinye, Justine Diana Namuli, Benedict Akimana, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6231690/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introduction: Children and adolescents living with HIV(CALWH) face significant mental health challenges, such as depression and anxiety, which negatively impact their HIV treatment outcomes. This study investigated the prevalence and factors associated with emotional problems among children and adolescents with unsuppressed viral loads in Northern Uganda. Methods: In 2021, 121 dyads of caregivers and CALWH (10 to 18 years) with unsuppressed viral loads were recruited from five community-based HIV clinics in Kitgum district. They were assessed for emotional problems using the Revised Child Anxiety and Depression Scale (RCADS-25), the Patterson Suicide Risk Assessment Tool and the Clinician-administered Post-traumatic Stress Disorder Scale for Children and Adolescents (CAPS-CA). Bivariate and multivariate analysis of the data was carried out using STATA version 18. Results: Emotional problems were observed in 61.97% of participants. Among these, depression was present in 45.45% of individuals, and all participants diagnosed with depression also exhibited significant comorbid anxiety symptoms. Notably, 16.52% of participants experienced anxiety without comorbid depression. Factors independently associated with emotional problems included food insecurity (p = 0.003; OR = 0.03), post-traumatic stress disorder (PTSD) (p < 0.0001; OR = 1.33), and high transportation costs to health facilities (p = 0.0069; OR = 1.00). However, no significant association was observed between emotional problems and gender (p = 0.94; χ² = 0.009). Conclusion : These results emphasize the importance of addressing underlying socio-economic and psychological factors to improve emotional well-being. Targeted interventions focused on reducing barriers to resources and providing mental health support are essential for fostering equitable mental health outcomes. Psychiatry Children and adolescents HIV Unsuppressed viral load Depression Anxiety Uganda problems Introduction There is an increasing number of children and adolescents living with HIV (CALWH), particularly in Sub-Saharan Africa (SSA), where over 41% of the world’s new HIV infections in children were reported in East and Central Africa in 2023 (1). This increase is partly due to the advancements in medical care which enable those born with HIV to survive longer (2–4). While this is a positive development, it brings significant challenges, including the uncertainties of navigating life as an HIV-positive individual, facing stigma, and experiencing social isolation (5–7). These challenges predispose the CALWH who are already vulnerable to emotional problems particularly depression and anxiety to further risk. Poverty and food insecurity further exacerbate the dire mental health situation among CALWH in low- and middle-income countries (LMICS) (8–10). The COVID-19 pandemic has significantly amplified these emotional challenges, creating a wave of mental health issues (11). Unfortunately, the data for the prevalence of these emotional problems is very scarce and frequently underestimated in LMICS, including rural northern Uganda, a post armed-conflict region. Children in post-conflict areas have been shown to exhibit increased prevalences of emotional problems, particularly Post Traumatic Stress Disorder (PTSD) (12,13). The underestimation of these challenges among children and adolescent (CA) in such areas is compounded by sociocultural factors and limited access to mental health resources as well as inadequate mental health awareness (14–16). Consequently, caregivers of CALWH, who have limited knowledge about mental health are left to play a crucial role in shaping the mental health outcomes of these children (17). This study aimed to estimate the prevalence of and factors associated with clinically significant depression and anxiety among HIV-positive children with detectable viral loads despite receiving antiretroviral therapy (ART). We hypothesized that HIV-positive children with unsuppressed viral loads in rural northern Uganda would experience high rates of depression and anxiety. Furthermore, we posited that their emotional well-being would be profoundly impacted by challenges such as poverty, food insecurity, and stigma. By examining these connections, this study seeks to illuminate the mental health struggles faced by this vulnerable population. The findings have the potential to inform targeted interventions and support systems that address their unique needs, emphasizing the importance of integrating mental health care into HIV treatment programs. Ultimately, this work aims to raise awareness of the emotional challenges faced by these children and advocate for policies and programs that prioritize their mental health and overall well-being. Materials And Methods Study Design This study employed a cross-sectional design to investigate the prevalence and factors associated with emotional problems among children and adolescents living with HIV (CALWH) who have detectable viral loads despite receiving antiretroviral therapy (ART) in rural northern Uganda. Data were collected from participants recruited from five community-based HIV clinics in Kitgum district. Clinic registers identified 121 CALWH aged 10–18 with viral loads exceeding 1,000 copies/mL. To ensure a comprehensive understanding of emotional problems, the study involved dyads consisting of the CALWH and their primary caregivers. Study Site This study was carried out in Kitgum district, one of the 7 districts that make up the Acholi subregion of Uganda, located over 400 kilometers north of the capital city of Uganda. At the time of the study, an estimated population of 232,000 individuals lived in this location. Over 90% of these residents were engaged in small-scale agriculture and animal husbandry for their livelihoods. The area's history is marked by a devastating civil war from 1987 to 2007, which resulted in significant disruptions to healthcare systems and loss of infrastructure. Presently in 2024, there are slightly over 239,000 individuals living in the district with over 56% of these being children between 0-17 years of age (18). This district has one of the poorest populations in the country where one in every three individuals lives in abject poverty (19). Study population: According to clinic records, 60% of young people on antiretroviral therapy (ART) were experiencing viral non-suppression at the time of the study design. 121 children and adolescents aged 10–18 years with detectable viral loads (>1000 copies/mL) were recruited through consecutive sampling to participate in a pilot trial of the adapted GSP model tailored for this age group. Before the trial began, baseline assessments were conducted, and a cross-sectional analysis was carried out to determine the prevalence of emotional problems and the associated factors. Participant Enrollment, Inclusion and Exclusion Criteria. The participants for this study were recruited in dyads consisting of the young person and their caregiver. The research assistants approached eligible dyads, detailed the study’s procedures, assessed eligibility, and secured informed assent from the youth and consent from the caregiver. Once consent was obtained, each dyad participated in a baseline assessment, which included a demographic survey and psychosocial evaluation. Medical records were assessed for the most recent viral load and reports of recurrent infections. To qualify for inclusion in the study, participant dyads needed to comprise an HIV-positive youth aged 10 to 18 years with a viral load exceeding 1,000 copies/ml. Research assistants (RAs) and study staff at HIV clinics collaborated with healthcare providers to identify potential participants during their medication refill visits. The RAs, fluent in the local language -Luo received comprehensive training on the study protocols and were monitored weekly by a project coordinator with a background in social work. To ensure participant safety, RAs conducted screenings for current psychotic and manic symptoms using the DSM-V symptom checklist for mania and psychotic symptoms. Additionally, study participants were evaluated for high suicide risk using the SAD PERSONS scale. Individuals showing signs of current psychosis, mania, or high suicide risk were linked to the mental health personnel at the health facility for further management and were excluded from participation. Study Measures The sociodemographic variables of the participants and their caregivers were assessed using an interviewer-administered standardized sociodemographic questionnaire. Children’s demographics included age, gender, and educational background. Age was recorded as a continuous variable. Gender was categorized as “female” or “male,” and education background was categorized as “primary/education” and “secondary education.” The caregiver’s sociodemographic questions included age, gender, marital status, level of education, and occupation. Age was also recorded as a continuous variable. Gender was categorized as “female” or “male.” Education background was categorized as “primary/education” and “secondary education.” Occupation was categorized into ‘‘unemployed,” “employed,” and “peasant farmer.” Relationship status was categorized into ‘‘never married,” “married/living with a partner,” “divorced/ separated,” or “widowed.” Additionally, the caregivers were asked whether they were involved in an income-generating activity and if there was food security. These responses were categorized into a “yes” or “no” Viral Load Monitoring For all participants initiating antiretroviral therapy (ART), viral load measurements are repeated six months after treatment initiation. Although the specific assay used to measure viral load was not documented, all testing was consistently conducted by the same laboratory, with results made available to the respective HIV clinics. Study participants' viral load data were obtained from their medical chart records at these clinics by our research assistants (RAs). The Revised Child Anxiety and Depression Scale (RCADS-25) was used to assess anxiety and depression symptoms. RCADS-25 is a 25-item self-report tool designed to assess anxiety and depression symptoms in children and adolescents. Each item is rated on a 4-point scale (0 = Never to 3 = Always), indicating the frequency of symptoms over the past week. The RCADS produces subscale scores for anxiety and depression and a total score for the two subscales. Anxiety-related items assess symptoms such as worry and nervousness, while depression items cover feelings of sadness, emptiness, and irritability. Higher scores indicate greater symptom severity. This scale has been widely used in Europe, North America, and South America, demonstrating high internal reliability (0.87-0.90) (20)(21), and strong psychometric properties, including a sensitivity of 90% and specificity of 75% (20–22). T-Score Conversion by Age and Gender: Raw subscale scores were converted to standardized T-scores based on each participant’s gender and grade or age group, using conversion tables provided by the Child First Lab. These tables offer age- and gender-specific norms to account for developmental differences, ensuring symptom severity is accurately interpreted across diverse age groups. Generally, a T-score of approximately 65 or above for anxiety and 70 or above for depression indicates clinically significant symptoms; however, exact thresholds depend on normative values specific to each demographic group. Suicide risk was assessed using the 10-item Patterson Suicide Risk Assessment Tool. The assessment tool includes 10 key indicators of suicide risk, including, depression, relationship status, an organized suicide plan, rational thinking loss and stated future suicide intent, age, gender, previous suicide attempts, excessive alcohol and drug use, and lack of social supports which are scored 1 when present, with higher scores indicating an increased risk. The scoring system categorizes risk as follows: scores below 2 indicate low risk, scores between 3 and 4 suggest mild risk, scores of 5 and 6 indicate moderate risk whereas scores of 8 or higher indicate high risk (23). The Clinician-administered post-traumatic stress disorder scale for children and adolescents (CAPS-CA) was used to assess PTSD symptoms. This tool assesses PTSD symptoms basing on four symptom clusters of; intrusion symptoms (Criterion B), avoidance symptoms (Criterion C), negative alterations in cognition and mood (Criterion D) and alterations in arousal and reactivity (Criterion E). The severity and frequency of each symptom from the clusters above is then rated on a 5-point scale (0 = Absent, to 4 = Extreme/Incapacitating). In order to meet the PTSD diagnosis, an individual had to have at least one positive symptom from criteria B and C and two symptoms from criteria D and E persisting for more than one month and causing functional impairment. The total PTSD severity score is the sum of all symptom severity scores across the four clusters, with higher scores indicating greater symptom burden. This tool has an internal reliability ranging from 0.83 to 0.92 , a high sensitivity of 90% and specificity of 75% (24–30). Therefore, although it has not been validated in Ugandan populations, its items have face validity. CAPS-CA scores were modeled as a continuous variable. Social support was assessed using the child and adolescent social support scale (CASS). This is a 40-item self-report tool developed to assess for social support across 5 subscales of parent, teacher, classmate, close friends, and people in the school. This assesses social support across four dimensions: emotional, informational, appraisal and instrumental across the 5 subscales. The frequency of this support is rated on a 6-point Likert scale, from 1 = Never to 6 = Always. The importance of each of this dimension of support to the individual is also rated on a 3-point Likert scale, from 1 = Not Important to 3 = Very Important. The sum of the ratings from both the frequency and importance parameters are computed for each subscale and a total for all the subscales obtained to get the overall perceived social support for an individual. Due to the COVID-19-induced lockdowns which led to closure of schools, only subscales of perceived social support from parents and close friends were evaluated as school aspects could not be effectively assessed under these circumstances. Although it has not been validated in Ugandan populations, its items have face validity. It’s internal consistency reliability coefficient ranges from 0.87 to 0.94) in studies conducted in Europe (31). The 8-item HIV stigma scale for children (HSSC-8) was used to assess stigma. This scale, adapted from HIV Stigma Scale (HSS) for use in children, assessing stigma across three different dimensions of fear of disclosure, experiences of discrimination, and feelings of self-stigma. Statements relating to the above dimensions were administered to the young people and these were rated on a 4-point Likert scale ranging from 1=Strongly agree to 4 = Strongly Agree. The total stigma score was calculated by summing the individual scores for each item. This tool has been used among young people with HIV and has been found to be reliable with an internal consistency reliability coefficient of 0.81 (32). Data analysis Statistical analyses were conducted using the Statistical Package for Social Sciences (SPSS for Windows, version 21). To explore factors associated with significant anxiety and depression, participants with T-scores above the cut-off for either condition were categorized as having "significant symptoms" (coded as 1), while those below the cut-off for both were categorized as having "no significant symptoms" (coded as 0). Bivariate logistic regression was initially performed to identify variables with associations significant at a p-value threshold of 0.2, which were then included in a multivariable logistic regression model to determine factors independently associated with significant anxiety and depression symptoms, adjusting for potential confounders. The multivariable model provided adjusted odds ratios to identify significant predictors after accounting for other variables. Ethical considerations The study was approved by both the Makerere University College of Health Sciences Research Ethics Committee and the Uganda National Council of Science and Technology. Every participant was reimbursed for transport costs based on the rate for the furthest participant and refreshments served after group support sessions. LHWs facilitating the group sessions received a financial incentive equivalent to 2.72USD per session. Results Description of study participants A total of 121 dyads of CALWH with unsurpressed viral loads and their caregivers were assessed for emotional problems and the associated factors. Table 1 shows the demographics of the young people and their caretakers recruited in the study. The mean age among children with emotional problems was 13.72 (SD = 2.82) and those without 13.61 (SD = 2.70). Overall, 60% of the CALWH were females while males constituted 40% of the young people. The age and gender showed equal distribution in both groups of children with emotional problems and those without having P-values of 0.92 and 0.83 respectively. Most caregivers were female in both groups (77.33% for children with emotional problems and 78.26% for children without) and married (75.68% in the emotional problems group and 80% in the non-emotional problems group). However, there was no significant association between caregiver sex or marital status and the child’s emotional status (p = 0.905 and 0.486 respectively). Most of the caregivers were peasant farmers with a small comparable percentage for both groups of children involved in an income generating activity. Food insecurity was found to be higher in children and adolescents with emotional problems (92%) than in those without (80.43%) Emotional Problems Among Children and Adolescents Living with HIV with Unsurpressed Viral Loads Depression and anxiety were assessed in 121 young people enrolled in this study as described in the methods section. Table 1 shows the distribution of emotional problems among the children. Children with emotional challenges exhibited a complex profile of depression and anxiety, with 45.45% showing symptoms of both, and 16.52% showing only anxiety. There were no cases of depression without anxiety in this population. Only 38.01% of the participants had neither depression nor anxiety. Furthermore, children with emotional problems exhibited higher scores for PTSD (mean = 29.67, SD = 10.53) and suicide risk (mean = 2.96, SD = 1.41) compared to those without emotional problems (PTSD: mean = 7.96, SD = 6.88; Suicide Risk: mean = 2.22, SD = 1.38). Stigma scores were comparable between the two groups. Table 1: Characteristics of the study participants. (N=121) Sociodemographic and Psychosocial Characteristics N (%) Sex Male Female 48 (39.67) 73 (60.33) Age 13.68 (2.77) * Caregiver Sex Male Female 27 (22.31) 94 (77.69) Caregiver Marital Status Single Married Widowed Divorced/Separated 13 (10.92) 92 (77.31) 11 (9.24) 3 (2.52) Caregiver Employment Status No employment Employed Peasant Farmer 49 (40.50) 4 (3.31) 68 (56.20) Income-Generating Activity Yes No 35 (28.93) 86 (71.07) Total Assets 3.31 (1.68) * Food Security Yes No 15 (12.40) 106 (87.60) Adherence to ART Yes No 81 (69.23) 36 (30.77) Suicide Risk Scores 2.68 (1.44) * Stigma Scores 22.94 (3.52) * PTSD Scores 21.41 (14.08) * Total Number of Infections 1.96 (1.79) * Perceived Social support from parents 40.26 (18.31) * Perceived Social Support from friends 38.54 (17.14) * Transport Costs to Health Facilities 5909.09 (4741.66) * Distance to Health Centers (KMs) 4.79 (3.44) * * Data presented as mean (SD) Table 2; Emotional Problems in Children and Adolescents(CA) Living with HIV with Unsuppressed viral loads EMOTIONAL PROBLEMS IN CHILDREN WITH HIV N (%) No Depression, No Anxiety 46(38.01) Has depression, No Anxiety 0(0) No Depression, Has Anxiety 20(16.52) Has Depression, Has Anxiety 55(45.45) Table 3; Bivariate Analyses: Factors associated with Emotional problems among CALWH Study Variable CA with Emotional Problems n (%) CA Without Emotional Problems n (%) Measure of Association (Chi-Square) P-Value Sex Males Females 30 (40) 45 (60) 18 (39.13) 28 (60.87) 0.0090 0.924 Age 13.72 (2.8215) 13.61 (2.7037) 0.8309 Caregiver Sex Male Female 17 (22.67) 58 (77.33) 10 (21.74) 36 (78.26) 0.0142 0.905 Caregiver Marital Status Single Married Widowed Divorced/Separated 9 (12.16) 56 (75.68) 6 (8.11) 3 (4.05) 4 (8.89) 36 (80) 5 (11.11) 0 (0) 2.4395 0.486 Employment Status No employment Employed Peasant Farmer 26 (34.67) 3 (4.0) 46 (61.33) 23 (50) 1 (2.17) 22 (47.83) 2.8686 0.238 Income-Generating Activity Yes No 22 (29.33) 53 (70.67) 13 (28.26) 33 (71.74) 0.0160 0.899 Food Security Yes No 6 (8) 69 (92.0) 19 (19.57) 37 (80.43) 3.5117 0.061 Total Assets 3.15 (1.68) 3.59 (1.76) 0.0861 Suicide Risk Scores 2.96 (1.41) 2.22 (1.38) 0.00054 Stigma scores 22.8 (3.87) 23.14 (2.85) 0.6406 PTSD Scores 29.67 (10.53) 7.96 (6.88) 0.6408 Perceived Social support from parents 35.84 (18.66) 47.48 (15.34) 0.0005 Perceived Social Support from friends 31.36 (15.42) 49.93 (13.19) 0.0000 Adherent to ART Non-Adherent to ART 46 (63.89) 26 (36.11) 35 (77.78) 10 (22.22) 2.5077 0.113 Total Number of Infections 2.2 (2) 1.57 (1.29) 0.0574 Transport Costs to Health Facilities 6813.33 (5374.35) 4434.78 (2978.83) 0.0069 Distance to Health Centers (KMs) 4.79 (3.32) 5.28 (3.62) 0.2226 Table 4: Multivariate Analyses: Factors Independently Associated with Emotional Problems in CALWH With Viral Non-Suppression Study Variable Odds ratio 95% Confidence Interval P-value Food Security 0.03 0.004 – 0.32 0.003 Caregiver employment Status 5.46 0.29 – 101.24 0.255 Total Number of Infections 0.47 0.25 – 0.90 0.023 Adherence to ART 0.67 0.11 – 4.0 0.661 Suicide Risk Scores 1.38 0.83 – 2.30 0.221 PTSD Scores 1.33 1.19 – 1.49 0.000 Transport Costs to Health Facilities 1.00 1.00 – 1.00 0.093 Distance to Health Centers (KMs) 0.81 0.59 – 1.11 0.186 Perceived Social support from parents 0.98 0.94 – 1.03 0.486 Perceived Social Support from friends 0.96 0.90 – 3.86 0.210 Discussion This study examined the prevalence and factors associated with emotional problems among children and adolescents living with HIV (CALWH) with viral non-suppression. The findings revealed a high prevalence of emotional problems, affecting 61.97% of participants, with significant anxiety symptoms present in all cases, making excessive anxiety the most common emotional problem in this population. This estimate is notably higher than those reported in previous studies. For example, the CHAKA study in Uganda, which assessed 1,339 children and adolescents using the Child and Adolescent Symptom Inventory-5 (CASI-5), found a 9% prevalence of anxiety disorders (33). Similarly, a study in Botswana using the Mini-International Neuropsychiatric Interview-Kid Screen (MINI-KID) reported an 18% prevalence among 743 adolescents (34). A recent systematic review and meta-analysis of psychiatric disorders among HIV-positive adolescents in sub-Saharan Africa reported a 26% prevalence of anxiety disorders (35). The prevalence of significant depression symptoms among affected participants was 45.45%, with all cases presenting comorbid considerable anxiety symptoms. This estimate aligns with findings by Kemigisha et al., who reported a 45% prevalence of depression among adolescents with HIV in Southwestern Uganda (36). However, studies from other African regions show much lower rates. The PopART trial in South Africa and Zambia reported a 27.6% prevalence of depression (37), while a systematic review and meta-analysis of psychiatric disorders among adolescents living with HIV in Sub-Saharan Africa found a pooled prevalence of 24% (35). Globally, depression affects an estimated 26.07% of adolescents with HIV (38). The discrepancy between our study and the CHAKA study may be due to the post-conflict setting of our study, where children faced greater stressors compared to non-conflict regions like those in the CHAKA study. Additionally, anxiety symptoms identified by screening tools tend to be more prevalent than full-blown anxiety disorders assessed by diagnostic tools. Our study assessed depression and anxiety using the Revised Child Anxiety and Depression Scale (RCADS-25), a screening tool for depression and anxiety. Participants who scored above the established cut-off points were classified as having significant symptoms of anxiety or depression. While the high prevalence reported in this study is concerning, it is important to account for methodological differences, such as the use of screening tools versus diagnostic assessments, when interpreting these findings. The comorbidity between depression and anxiety is well-documented, as prior research indicates that depression in children and adolescents often co-occurs with anxiety, sharing common risk factors and distinct neurostructural patterns (39–41). Our study extends these findings to children and adolescents living with HIV (CALWH) with unsuppressed viral loads, showing that depression in this population is almost invariably accompanied by anxiety. We recommend that screening for both anxiety and depression be integrated into HIV care packages, as these common mental health disorders have been shown to negatively impact HIV treatment outcomes, as demonstrated in studies from Uganda (42), South Africa (43), and Mozambique (44). The second major finding in this study was that these emotional problems were independently associated with food insecurity, post-traumatic stress symptoms, and higher transport costs to the health facilities. Previous research indicates that food insecurity can lead to various mental health issues, including depressive symptoms and anxiety, among young people living with HIV(45). Studies in both high-income and low-income countries have linked food insecurity to emotional problems. A systematic review of 23 peer-reviewed articles from developed countries showed that household food insecurity was associated with emotional problems(46). A study of young people in Eastern Zambia found that nearly half of the participants experienced severe food insecurity, which was significantly associated with higher levels of depressive symptoms (8). Regarding post-traumatic stress symptoms, previous studies have documented that children with chronic illnesses are at an increased risk of developing post-traumatic stress disorder (PTSD) due to various factors, including subjective experiences of trauma, family dysfunctions and low support, and parental traumas and poor mental health (47–49). In our study population, some of the challenges reported by the CALWH in a qualitative study included inadequate care and negative attitudes from their parents, who sometimes view them as outcasts (50). Such attitudes from family members are detrimental, as they reinforce feelings of worthlessness and hopelessness. Transport costs have been recognized as a significant contributor to the economic burden faced by caregivers of children living with HIV (51). In this study, transport costs were independently associated with emotional problems, despite CALWH with emotional problems residing closer to health facilities compared to those without such issues. Additionally, CALWH with emotional problems reported a higher frequency of recurrent infections than their counterparts without emotional problems. We hypothesize that the elevated transport costs stem from more frequent visits to healthcare facilities required to manage recurrent infections and comorbid conditions. This highlights the interconnected nature of emotional problems, health complications, and economic burden in this population. An important negative finding in this study is the lack of association between emotional problems and gender. Previous research on this topic has shown mixed results. Two South African studies using the Child Behavior Checklist (CBCL) found that emotional problems were similarly distributed across genders among children and adolescents living with HIV (52,53). In contrast, a systematic review by Ayano et al. reported higher rates of depression among female adolescents, while studies in Mozambique and South Africa observed higher prevalences of anxiety in females compared to males (38,54,55). These findings highlight the importance of adopting a gender-neutral approach when screening for and addressing emotional problems among children and adolescents living with HIV (CALWH), ensuring that interventions are inclusive and equitable for all genders. Another notable negative finding was that CALWH with emotional problems had a higher risk of suicide, although this association did not reach statistical significance in multivariate analyses. Previous studies have shown that CALWH in Uganda are at increased risk for suicidal ideation (56), a disheartening trend also observed among children in Rwanda and South Africa (57) (58). These findings emphasize the urgent need to integrate routine suicide screening into HIV care for CALWH. Additionally, CALWH who were adherent to ART were less likely to experience emotional problems, though this association also did not achieve statistical significance. Emotional problems, including depression, anxiety, and emotional unawareness, are known to interfere significantly with adherence to antiretroviral therapy (ART) in this population. Addressing these emotional challenges remains crucial for improving HIV treatment outcomes. Limitations of the Study This study has some limitations that should be considered when interpreting the findings. Firstly, while the Revised Child Anxiety and Depression Scale (RCADS-25) and other tools used have strong psychometric properties, they have not been validated explicitly for CALWH in Uganda. Cultural differences in the expression of emotional distress may affect the accuracy of these measures in this context. Secondly, although the study was adequately powered for most analyses, the sample size may have been insufficient to detect subtle associations in subgroup analyses, particularly for certain sociodemographic and psychosocial variables. Lastly, the study was conducted in a single rural, post-conflict district. While Kitgum reflects similar contexts in northern Uganda, the findings may not be generalizable to urban areas or regions with differing sociocultural and healthcare dynamics. Despite these limitations, this study provides important insights into the emotional health challenges of CALWH in rural Uganda. It underscores the need for integrated mental health care within HIV treatment programs. Screening for mental health conditions should be a routine component of HIV care to facilitate early identification. Interventions such as group support psychotherapy(GSP) can support caregivers of CALWH and be adapted to address the emotional problems of CALWH. To strengthen these findings, future research should explore longitudinal designs, larger and more diverse samples, and use culturally validated tools. Conclusion This study underscores the substantial burden of emotional problems among children and adolescents living with HIV (CALWH) who experience viral non-suppression in rural northern Uganda. These findings reveal a complex interplay between psychological challenges, such as depression and anxiety, and socio-economic factors, including poverty and food insecurity. The association between emotional distress and these hardships highlights the multidimensional vulnerabilities faced by this population, which extend beyond the clinical management of HIV. By shedding light on the prevalence and drivers of emotional problems in CALWH, the study emphasizes the need for integrated care models that address both mental health and socio-economic determinants of well-being. These insights underscore the urgency of incorporating mental health support into HIV treatment programs and ensuring access to resources that mitigate structural barriers. Addressing these intertwined challenges is critical for improving treatment outcomes, enhancing quality of life, and fostering resilience among this vulnerable group. Declarations Funding : This work is part of a research project funded by several small grants from CRI Foundation through FIDELITY Charitable International Grants; Grant ID Numbers: 13624790, 12977146, 14789811, 15884099, 16583402 References Unaids. 2024 global AIDS report — The Urgency of Now: AIDS at a Crossroads [Internet]. 2024. Available from: http://www.wipo.int/ Slogrove AL, Mahy M, Armstrong A, Davies M. Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic. J Int AIDS Soc. 2017 May 16;20(S3). Davies MA, Gibb D, Turkova A. Survival of HIV-1 vertically infected children. Curr Opin HIV AIDS. 2016 Sep;11(5):455–64. Bernays S, Jarrett P, Kranzer K, Ferrand RA. Children growing up with HIV infection: the responsibility of success. The Lancet. 2014 Apr;383(9925):1355–7. Faidas M, Stockton MA, Mphonda SM, Sansbury G, Hedrick H, Devadas J, et al. 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Olashore AA, Paruk S, Akanni OO, Tomita A, Chiliza B. Psychiatric Disorders in Adolescents Living with HIV and Association with Antiretroviral Therapy Adherence in Sub-Saharan Africa: A Systematic Review and Meta-analysis. AIDS Behav. 2021 Jun 20;25(6):1711–28. Kemigisha E, Zanoni B, Bruce K, Menjivar R, Kadengye D, Atwine D, et al. Prevalence of depressive symptoms and associated factors among adolescents living with HIV/AIDS in South Western Uganda. AIDS Care. 2019 Oct 3;31(10):1297–303. Shanaube K, Gachie T, Hoddinott G, Schaap A, Floyd S, Mainga T, et al. Depressive symptoms and HIV risk behaviours among adolescents enrolled in the HPTN071 (PopART) trial in Zambia and South Africa. PLoS One. 2022 Dec 1;17(12):e0278291. Ayano G, Demelash S, Abraha M, Tsegay L. The prevalence of depression among adolescent with HIV/AIDS: a systematic review and meta-analysis. AIDS Res Ther. 2021 Dec 27;18(1):23. Axelson DA, Birmaher B. Relation between anxiety and depressive disorders in childhood and adolescence. Depress Anxiety. 2001;14(2):67–78. Konac D, Young K, Lau J, Barker E. Comorbidity Between Depression and Anxiety in Adolescents: Bridge Symptoms and Relevance of Risk and Protective Factors. J Psychopathol Behav Assess [Internet]. 2021;43:583–96. Available from: https://consensus.app/papers/comorbidity-between-depression-and-anxiety-in-konac-young/77cfc5c82fb85812b7f67f62e1c2d53a/ Chen C. Recent advances in the study of the comorbidity of depressive and anxiety disorders. Adv Clin Exp Med [Internet]. 2022; Available from: https://consensus.app/papers/recent-advances-in-the-study-of-the-comorbidity-of-chen/fe57342f296350b58e65d656fb5c0f7c/ Kinyanda E, Nakasujja N, Levin J, Birabwa H, Mpango R, Grosskurth H, et al. Major depressive disorder and suicidality in early HIV infection and its association with risk factors and negative outcomes as seen in semi-urban and rural Uganda. J Affect Disord [Internet]. 2017;212:117–27. Available from: https://consensus.app/papers/major-depressive-disorder-and-suicidality-in-early-hiv-kinyanda-nakasujja/2a56835ec3785d45acce08609fcd34a8/ Haas AD, Lienhard R, Didden C, Cornell M, Folb N, Boshomane TMG, et al. Mental Health, ART Adherence, and Viral Suppression Among Adolescents and Adults Living with HIV in South Africa: A Cohort Study. AIDS Behav. 2023 Jun 2;27(6):1849–61. Nguyen N, Lovero KL, Falcao J, Brittain K, Zerbe A, Wilson IB, et al. Mental health and ART adherence among adolescents living with HIV in Mozambique. AIDS Care. 2023 Feb 1;35(2):182–90. Rosen JG, Mbizvo MT, Phiri L, Chibuye M, Namukonda ES, Kayeyi N. Depression-Mediating Pathways From Household Adversity to Antiretroviral Therapy Nonadherence Among Children and Adolescents Living With HIV in Zambia: A Structural Equation Modeling Approach. JAIDS Journal of Acquired Immune Deficiency Syndromes. 2023 Jul 1;93(3):191–8. Shankar P, Chung R, Frank DA. Association of Food Insecurity with Children’s Behavioral, Emotional, and Academic Outcomes: A Systematic Review. Journal of Developmental & Behavioral Pediatrics. 2017 Feb;38(2):135–50. Carmassi C, Dell’Oste V, Foghi C, Bertelloni CA, Conti E, Calderoni S, et al. Post-Traumatic Stress Reactions in Caregivers of Children and Adolescents/Young Adults with Severe Diseases: A Systematic Review of Risk and Protective Factors. Int J Environ Res Public Health. 2020 Dec 29;18(1):189. Pinquart M. Posttraumatic Stress Symptoms and Disorders in Parents of Children and Adolescents With Chronic Physical Illnesses: A Meta‐Analysis. J Trauma Stress. 2019 Feb 28;32(1):88–96. Beveridge JK, Neville A, Wilson AC, Noel M. Intergenerational examination of pain and posttraumatic stress disorder symptoms among youth with chronic pain and their parents. Pain Rep. 2018 Sep;3(7):e667. Nakimuli-Mpungu E, Wamala K, Nakanyike C, Iya J, Lukyamuzi Z, Diana Namuli J, et al. Developing and Testing Group Support Psychotherapy for Children and Adolescents Living with HIV in Uganda. In: Psychotherapy - New Trends and Developments [Working Title]. IntechOpen; 2024. Katana P V., Abubakar A, Nyongesa MK, Ssewanyana D, Mwangi P, Newton CR, et al. Economic burden and mental health of primary caregivers of perinatally HIV infected adolescents from Kilifi, Kenya. BMC Public Health. 2020 Dec 16;20(1):504. Visser MJ, Hecker HE, Jordaan J. A comparative study of the psychological problems of HIV-infected and HIV-uninfected children in a South African sample. AIDS Care. 2018 May 4;30(5):596–603. Louw KA, Ipser J, Phillips N, Hoare J. Correlates of emotional and behavioural problems in children with perinatally acquired HIV in Cape Town, South Africa. AIDS Care. 2016 Jul 2;28(7):842–50. Di Gennaro F, Marotta C, Ramirez L, Cardoso H, Alamo C, Cinturao V, et al. High Prevalence of Mental Health Disorders in Adolescents and Youth Living with HIV: An Observational Study from Eight Health Services in Sofala Province, Mozambique. AIDS Patient Care STDS. 2022 Apr 1;36(4):123–9. Sherr L, Cluver LD, Toska E, He E. Differing psychological vulnerabilities among behaviourally and perinatally HIV infected adolescents in South Africa – implications for targeted health service provision. AIDS Care. 2018 Jun 20;30(sup2):92–101. Namuli JD, Nalugya JS, Bangirana P, Nakimuli-Mpungu E. Prevalence and Factors Associated With Suicidal Ideation Among Children and Adolescents Attending a Pediatric HIV Clinic in Uganda. Frontiers in Sociology. 2021 Jun 15;6. Uwiringiyimana A, Niyonsenga J, Lisette KG, Bugenimana A, Mutabaruka J, Nshimiyimana A. Depression symptoms and suicidal ideation among HIV infected Rwandans: the mediating and moderating effects of complicated grief and substance abuse. AIDS Res Ther. 2024 Jun 7;21(1):38. Casale M, Boyes M, Pantelic M, Toska E, Cluver L. Suicidal thoughts and behaviour among South African adolescents living with HIV: Can social support buffer the impact of stigma? J Affect Disord. 2019 Feb;245:82–90. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6231690","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":429146555,"identity":"6227a8f8-d838-45a5-a4c5-1698f073c1ea","order_by":0,"name":"Jeremiah Kwesiga Mutinye","email":"","orcid":"","institution":"Medical Research Council, Uganda Virus Research Institute and London School of Hygiene and Tropical Medicine (MRC/UVRI/ LSHTM ) Research Unit, Entebbe, 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and Tropical Medicine (MRC/UVRI/ LSHTM ) Research Unit, Entebbe, Uganda","correspondingAuthor":true,"prefix":"","firstName":"Etheldreda","middleName":"","lastName":"Nakimuli-Mpungu","suffix":""}],"badges":[],"createdAt":"2025-03-15 08:54:57","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6231690/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6231690/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":78720960,"identity":"1e2a3b2a-15f3-4657-aabf-d514f5baa501","added_by":"auto","created_at":"2025-03-18 04:39:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1068985,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6231690/v1/5fb84f21-169d-405a-8162-43b79081523e.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003ePrevalence and Factors Associated with Emotional Problems Among HIV-Positive Children and Adolescents with Viral Non-Suppression in Rural Northern Uganda.\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere is an increasing number of children and adolescents living with HIV (CALWH), particularly in Sub-Saharan Africa (SSA), where over 41% of the world\u0026rsquo;s new HIV infections in children were reported in East and Central Africa in 2023 (1). This increase is partly due to the advancements in medical care which enable those born with HIV to survive longer (2\u0026ndash;4). While this is a positive development, it brings significant challenges, including the uncertainties of navigating life as an HIV-positive individual, facing stigma, and experiencing social isolation (5\u0026ndash;7). These challenges predispose the CALWH who are already vulnerable to emotional problems particularly depression and anxiety to further risk.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePoverty and food insecurity further exacerbate the dire mental health situation among CALWH in low- and middle-income countries (LMICS) \u0026nbsp;(8\u0026ndash;10). The COVID-19 pandemic has significantly amplified these emotional challenges, creating a wave of mental health issues (11). Unfortunately, the data for the prevalence of these emotional problems is very scarce and frequently underestimated in LMICS, including rural northern Uganda, a post armed-conflict region. Children in post-conflict areas have been shown to exhibit increased prevalences of emotional problems, particularly Post Traumatic Stress Disorder (PTSD) \u0026nbsp;(12,13). \u0026nbsp;The underestimation of these challenges among children and adolescent (CA) in such areas is compounded by sociocultural factors and limited access to mental health resources as well as inadequate mental health awareness \u0026nbsp; (14\u0026ndash;16). \u0026nbsp;Consequently, caregivers of CALWH, who have limited knowledge about mental health are left to play a crucial role in shaping the mental health outcomes of these children (17).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study aimed to estimate the prevalence of and factors associated with clinically significant depression and anxiety among HIV-positive children with detectable viral loads despite receiving antiretroviral therapy (ART). We hypothesized that HIV-positive children with unsuppressed viral loads in rural northern Uganda would experience high rates of depression and anxiety. Furthermore, we posited that their emotional well-being would be profoundly impacted by challenges such as poverty, food insecurity, and stigma.\u003c/p\u003e\n\u003cp\u003eBy examining these connections, this study seeks to illuminate the mental health struggles faced by this vulnerable population. The findings have the potential to inform targeted interventions and support systems that address their unique needs, emphasizing the importance of integrating mental health care into HIV treatment programs. Ultimately, this work aims to raise awareness of the emotional challenges faced by these children and advocate for policies and programs that prioritize their mental health and overall well-being.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study employed a cross-sectional design to investigate the prevalence and factors associated with emotional problems among children and adolescents living with HIV (CALWH) who have detectable viral loads despite receiving antiretroviral therapy (ART) in rural northern Uganda.\u003c/p\u003e\n\u003cp\u003eData were collected from participants recruited from five community-based HIV clinics in Kitgum district. Clinic registers identified 121 CALWH aged 10\u0026ndash;18 with viral loads exceeding 1,000 copies/mL. To ensure a comprehensive understanding of emotional problems, the study involved dyads consisting of the CALWH and their primary caregivers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Site\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was carried out in Kitgum district, one of the 7 districts that make up the Acholi subregion of Uganda, located over 400 kilometers north of the capital city of Uganda. At the time of the study, an estimated population of 232,000 individuals lived in this location. Over 90% of these residents were engaged in small-scale agriculture and animal husbandry for their livelihoods. The area\u0026apos;s history is marked by a devastating civil war from 1987 to 2007, which resulted in significant disruptions to healthcare systems and loss of infrastructure. Presently in 2024, there are slightly over 239,000 individuals living in the district with over 56% of these being children between 0-17 years of age (18).\u0026nbsp;This district has one of the poorest populations in the country where one in every three individuals lives in abject poverty (19).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy population:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAccording to clinic records, 60% of young people on antiretroviral therapy (ART) were experiencing viral non-suppression at the time of the study design. 121 children and adolescents aged 10\u0026ndash;18 years with detectable viral loads (\u0026gt;1000 copies/mL) were recruited through consecutive sampling to participate in a pilot trial of the adapted GSP model tailored for this age group. Before the trial began, baseline assessments were conducted, and a cross-sectional analysis was carried out to determine the prevalence of emotional problems and the associated factors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipant Enrollment, Inclusion and Exclusion Criteria.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe participants for this study were recruited in dyads consisting of the young person and their caregiver. The research assistants approached eligible dyads, detailed the study\u0026rsquo;s procedures, assessed eligibility, and secured informed assent from the youth and consent from the caregiver. Once consent was obtained, each dyad participated in a baseline assessment, which included a demographic survey and psychosocial evaluation. Medical records were assessed for the\u0026nbsp;most recent viral load and reports of recurrent infections.\u003c/p\u003e\n\u003cp\u003eTo qualify for inclusion in the study, participant dyads needed to comprise an HIV-positive youth aged 10 to 18 years with a viral load exceeding 1,000 copies/ml. Research assistants (RAs) and study staff at HIV clinics collaborated with healthcare providers to identify potential participants during their medication refill visits. The RAs, fluent in the local language -Luo received comprehensive training on the study protocols and were monitored weekly by a project coordinator with a background in social work.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo ensure participant safety, RAs conducted screenings for current psychotic and manic symptoms using the DSM-V symptom checklist for mania and psychotic symptoms. Additionally, study participants were evaluated for high suicide risk using the SAD PERSONS scale. Individuals showing signs of current psychosis, mania, or high suicide risk were linked to the mental health personnel at the health facility for further management and were excluded from participation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Measures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe sociodemographic variables of the participants and their caregivers were assessed using an interviewer-administered standardized sociodemographic questionnaire.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eChildren\u0026rsquo;s demographics included age, gender, and educational background. Age was recorded as a continuous variable. Gender was categorized as \u0026ldquo;female\u0026rdquo; or \u0026ldquo;male,\u0026rdquo; and education background was categorized as \u0026ldquo;primary/education\u0026rdquo; and \u0026ldquo;secondary education.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eThe caregiver\u0026rsquo;s sociodemographic questions included age, gender, marital status, level of education, and occupation. Age was also recorded as a continuous variable. Gender was categorized as \u0026ldquo;female\u0026rdquo; or \u0026ldquo;male.\u0026rdquo; Education background was categorized as \u0026ldquo;primary/education\u0026rdquo; and \u0026ldquo;secondary education.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eOccupation was categorized into \u0026lsquo;\u0026lsquo;unemployed,\u0026rdquo; \u0026ldquo;employed,\u0026rdquo; and \u0026ldquo;peasant farmer.\u0026rdquo; Relationship status was categorized into \u0026lsquo;\u0026lsquo;never married,\u0026rdquo; \u0026ldquo;married/living with a partner,\u0026rdquo; \u0026ldquo;divorced/ separated,\u0026rdquo; or \u0026ldquo;widowed.\u0026rdquo; Additionally, the caregivers were asked whether they were involved in an income-generating activity and if there was food security. These responses were categorized into a \u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eViral Load Monitoring\u0026nbsp;\u003c/em\u003eFor all participants initiating antiretroviral therapy (ART), viral load measurements are repeated six months after treatment initiation. Although the specific assay used to measure viral load was not documented, all testing was consistently conducted by the same laboratory, with results made available to the respective HIV clinics. Study participants\u0026apos; viral load data were obtained from their medical chart records at these clinics by our research assistants (RAs).\u003c/p\u003e\n\u003cp\u003eThe Revised Child Anxiety and Depression Scale (RCADS-25) was used to assess anxiety and depression symptoms. RCADS-25 is a 25-item self-report tool designed to assess anxiety and depression symptoms in children and adolescents. Each item is rated on a 4-point scale (0 = Never to 3 = Always), indicating the frequency of symptoms over the past week. The RCADS produces subscale scores for anxiety and depression and a total score for the two subscales. Anxiety-related items assess symptoms such as worry and nervousness, while depression items cover feelings of sadness, emptiness, and irritability. Higher scores indicate greater symptom severity. This scale has been widely used in Europe, North America, and South America, demonstrating high internal reliability (0.87-0.90) (20)(21), and strong psychometric properties, including a sensitivity of 90% and specificity of 75% (20\u0026ndash;22).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eT-Score Conversion by Age and Gender:\u003c/em\u003e Raw subscale scores were converted to standardized T-scores based on each participant\u0026rsquo;s gender and grade or age group, using conversion tables provided by the Child First Lab. These tables offer age- and gender-specific norms to account for developmental differences, ensuring symptom severity is accurately interpreted across diverse age groups. Generally, a T-score of approximately 65 or above for anxiety and 70 or above for depression indicates clinically significant symptoms; however, exact thresholds depend on normative values specific to each demographic group.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSuicide risk\u003c/em\u003e was assessed using the 10-item Patterson Suicide Risk Assessment Tool. The assessment tool includes 10 key indicators of suicide risk, including, depression, relationship status, an organized suicide plan, rational thinking loss and stated future suicide intent, age, gender, previous suicide attempts, excessive alcohol and drug use, and lack of social supports which are scored 1 when present, with higher scores indicating an increased risk. The scoring system categorizes risk as follows: scores below 2 indicate low risk, scores between 3 and 4 suggest mild risk, scores of 5 and 6 indicate moderate risk whereas scores of 8 or higher indicate high risk (23).\u003c/p\u003e\n\u003cp\u003eThe Clinician-administered post-traumatic stress disorder scale for children and adolescents (CAPS-CA) was used to assess PTSD symptoms. This tool assesses PTSD symptoms basing on four symptom clusters of; intrusion symptoms (Criterion B), avoidance symptoms (Criterion C), negative alterations in cognition and mood (Criterion D) and alterations in arousal and reactivity (Criterion E). \u0026nbsp;The severity and frequency of each symptom from the clusters above is then rated on a 5-point scale (0 = Absent, to 4 = Extreme/Incapacitating). In order to meet the PTSD diagnosis, an individual had to have at least one positive symptom from criteria B and C and two symptoms from criteria D and E persisting for more than one month and causing functional impairment. The total PTSD severity score is the sum of all symptom severity scores across the four clusters, with higher scores indicating greater symptom burden. This tool has an internal reliability ranging from 0.83 to 0.92 \u0026nbsp; , a high sensitivity of 90% and specificity of 75% (24\u0026ndash;30). Therefore, although it has not been validated in Ugandan populations, its items have face validity. CAPS-CA scores were modeled as a continuous variable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSocial support\u003c/em\u003e was assessed using the child and adolescent social support scale (CASS). This is a 40-item self-report tool developed to assess for social support across 5 subscales of parent, teacher, classmate, close friends, and people in the school. This assesses social support across four dimensions: emotional, informational, appraisal and instrumental across the 5 subscales. The frequency of this support is rated on a 6-point Likert scale, from \u003cem\u003e1 = Never\u003c/em\u003e to \u003cem\u003e6 = Always.\u0026nbsp;\u003c/em\u003eThe importance of each of this dimension of support to the individual is also rated on a 3-point Likert scale, from \u003cem\u003e1 = Not Important\u003c/em\u003e to \u003cem\u003e3 = Very Important.\u0026nbsp;\u003c/em\u003e The sum of the ratings from both the frequency and importance parameters are computed for each subscale and a total for all the subscales obtained to get the overall perceived social support for an individual. Due to the COVID-19-induced lockdowns which led to closure of schools, only subscales of perceived social support from parents and close friends were evaluated as school aspects could not be effectively assessed under these circumstances. Although it has not been validated in Ugandan populations, its items have face validity. It\u0026rsquo;s internal consistency reliability coefficient ranges from 0.87 to 0.94) in studies conducted in Europe (31).\u003c/p\u003e\n\u003cp\u003eThe 8-item HIV stigma scale for children (HSSC-8) was used to assess stigma. This scale, adapted from HIV Stigma Scale (HSS) for use in children, assessing stigma across three different dimensions of fear of disclosure, experiences of discrimination, and feelings of self-stigma. Statements relating to the above dimensions were administered to the young people and these were rated on a 4-point Likert scale ranging from 1=Strongly agree to 4 = Strongly Agree. The total stigma score was calculated by summing the individual scores for each item. This tool has been used among young people with HIV and has been found to be reliable with an internal consistency reliability coefficient of 0.81 (32).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eStatistical analyses were conducted using the Statistical Package for Social Sciences (SPSS for Windows, version 21). To explore factors associated with significant anxiety and depression, participants with T-scores above the cut-off for either condition were categorized as having \u0026quot;significant symptoms\u0026quot; (coded as 1), while those below the cut-off for both were categorized as having \u0026quot;no significant symptoms\u0026quot; (coded as 0). Bivariate logistic regression was initially performed to identify variables with associations significant at a p-value threshold of 0.2, which were then included in a multivariable logistic regression model to determine factors independently associated with significant anxiety and depression symptoms, adjusting for potential confounders. The multivariable model provided adjusted odds ratios to identify significant predictors after accounting for other variables.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by both the Makerere University College of Health Sciences Research Ethics Committee and the Uganda National Council of Science and Technology.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvery participant was reimbursed for transport costs based on the rate for the furthest participant and refreshments served after group support sessions. LHWs facilitating the group sessions received a financial incentive equivalent to 2.72USD per session.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eDescription of study participants\u003c/h2\u003e\n\u003cp\u003eA total of 121 dyads of CALWH with unsurpressed viral loads and their caregivers were assessed for emotional problems and the associated factors. \u003cem\u003eTable 1\u003c/em\u003e shows the demographics of the young people and their caretakers recruited in the study.\u0026nbsp;The mean age among children with emotional problems was 13.72 (SD = 2.82) and those without 13.61 (SD = 2.70). \u0026nbsp;Overall, 60% of the CALWH were females while males constituted 40% of the young people. The age and gender showed equal distribution in both groups of children with emotional problems and those without having P-values of 0.92 and 0.83 respectively.\u003c/p\u003e\n\u003cp\u003eMost caregivers were female in both groups (77.33% for children with emotional problems and 78.26% for children without) and married (75.68% in the emotional problems group and 80% in the non-emotional problems group). However, there was no significant association between caregiver sex or marital status and the child\u0026rsquo;s emotional status (p = 0.905 and 0.486 respectively). Most of the caregivers were peasant farmers with a small comparable percentage for both groups of children involved in an income generating activity. Food insecurity was found to be higher in children and adolescents with emotional problems (92%) than in those without (80.43%)\u003c/p\u003e\n\u003ch2\u003eEmotional Problems Among Children and Adolescents Living with HIV with Unsurpressed Viral Loads\u003c/h2\u003e\n\u003cp\u003eDepression and anxiety were assessed in 121 young people enrolled in this study as described in the methods section. Table 1 shows the distribution of emotional problems among the children. Children with emotional challenges exhibited a complex profile of depression and anxiety, with 45.45% showing symptoms of both, and 16.52% showing only anxiety. There were no cases of depression without anxiety in this population. Only 38.01% of the participants had neither depression nor anxiety.\u003c/p\u003e\n\u003cp\u003eFurthermore, children with emotional problems exhibited higher scores for PTSD (mean = 29.67, SD = 10.53) and suicide risk (mean = 2.96, SD = 1.41) compared to those without emotional problems (PTSD: mean = 7.96, SD = 6.88; Suicide Risk: mean = 2.22, SD = 1.38). Stigma scores were comparable between the two groups.\u003c/p\u003e\n\u003cp\u003eTable 1: Characteristics of the study participants. (N=121)\u003c/p\u003e\n\u003cdiv\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"493\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSociodemographic and Psychosocial Characteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e48 (39.67)\u003c/p\u003e\n \u003cp\u003e73 (60.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e13.68 (2.77)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Sex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e27 (22.31)\u003c/p\u003e\n \u003cp\u003e94 (77.69)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Marital Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003cp\u003eDivorced/Separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e13 (10.92)\u003c/p\u003e\n \u003cp\u003e92 (77.31)\u003c/p\u003e\n \u003cp\u003e11 (9.24)\u003c/p\u003e\n \u003cp\u003e3 (2.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Employment Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo employment\u003c/p\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003cp\u003ePeasant Farmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e49 (40.50)\u003c/p\u003e\n \u003cp\u003e4 (3.31)\u003c/p\u003e\n \u003cp\u003e68 (56.20)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome-Generating Activity\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e35 (28.93)\u003c/p\u003e\n \u003cp\u003e86 (71.07)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Assets\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e3.31 (1.68)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood Security\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (12.40)\u003c/p\u003e\n \u003cp\u003e106 (87.60)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdherence to ART\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e81 (69.23)\u003c/p\u003e\n \u003cp\u003e36 (30.77)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSuicide Risk Scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e2.68 (1.44)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStigma Scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e22.94 (3.52)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePTSD Scores\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e21.41 (14.08)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal Number of Infections\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e1.96 (1.79)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Social support from parents\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e40.26 (18.31)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Social Support from friends\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e38.54 (17.14)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTransport Costs to Health Facilities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e5909.09 (4741.66)\u003csup\u003e*\u003c/sup\u003e\u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 70.3252%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistance to Health Centers (KMs)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.6748%;\"\u003e\n \u003cp\u003e4.79 (3.44)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003csup\u003e*\u003c/sup\u003eData presented as mean (SD)\u003c/p\u003e\n\u003cp\u003eTable 2; Emotional Problems in Children and Adolescents(CA) Living with HIV with Unsuppressed viral\u0026nbsp;loads\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEMOTIONAL PROBLEMS IN CHILDREN WITH HIV\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eN (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo Depression, No Anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e46(38.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHas depression, No Anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e0(0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo Depression, Has Anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e20(16.52) \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHas Depression, Has Anxiety\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e55(45.45)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 3; Bivariate Analyses: Factors associated with Emotional problems among CALWH\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Variable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA with Emotional Problems\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCA Without Emotional Problems n (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeasure of Association (Chi-Square)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-Value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMales\u003c/p\u003e\n \u003cp\u003eFemales\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e30 (40)\u003c/p\u003e\n \u003cp\u003e45 (60)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18 (39.13)\u003c/p\u003e\n \u003cp\u003e28 (60.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.0090\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.924\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e13.72 (2.8215)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e13.61 (2.7037) \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.8309 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Sex\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17 (22.67)\u003c/p\u003e\n \u003cp\u003e58 (77.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (21.74)\u003c/p\u003e\n \u003cp\u003e36 (78.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e0.0142\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.905\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCaregiver Marital Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eSingle\u003c/p\u003e\n \u003cp\u003eMarried\u003c/p\u003e\n \u003cp\u003eWidowed\u003c/p\u003e\n \u003cp\u003eDivorced/Separated\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e9 (12.16)\u003c/p\u003e\n \u003cp\u003e56 (75.68)\u003c/p\u003e\n \u003cp\u003e6 (8.11)\u003c/p\u003e\n \u003cp\u003e3 (4.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e4 (8.89)\u003c/p\u003e\n \u003cp\u003e36 (80)\u003c/p\u003e\n \u003cp\u003e5 (11.11)\u003c/p\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.4395\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEmployment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eStatus\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eNo employment\u003c/p\u003e\n \u003cp\u003eEmployed\u003c/p\u003e\n \u003cp\u003ePeasant Farmer\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e26 (34.67)\u003c/p\u003e\n \u003cp\u003e3 (4.0)\u003c/p\u003e\n \u003cp\u003e46 (61.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e23 (50)\u003c/p\u003e\n \u003cp\u003e1 (2.17)\u003c/p\u003e\n \u003cp\u003e22 (47.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e2.8686\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.238\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIncome-Generating Activity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e22 (29.33)\u003c/p\u003e\n \u003cp\u003e53 (70.67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e13 (28.26)\u003c/p\u003e\n \u003cp\u003e33 (71.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e0.0160\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.899\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 643px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFood Security\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e6 (8)\u003c/p\u003e\n \u003cp\u003e69 (92.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e19 (19.57)\u003c/p\u003e\n \u003cp\u003e37 (80.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e3.5117\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.061\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eTotal Assets\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e3.15 (1.68)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e3.59 (1.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.0861\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eSuicide Risk Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e2.96 (1.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e2.22 (1.38)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.00054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eStigma scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e22.8 (3.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e23.14 (2.85)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.6406\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003ePTSD Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e29.67 (10.53)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e7.96 (6.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.6408\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003ePerceived Social support from parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e35.84 (18.66)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e47.48 (15.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.0005\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003ePerceived Social Support from friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e31.36 (15.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e49.93 (13.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.0000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eAdherent to ART\u003c/p\u003e\n \u003cp\u003eNon-Adherent to ART\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e46 (63.89)\u003c/p\u003e\n \u003cp\u003e26 (36.11)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e35 (77.78)\u003c/p\u003e\n \u003cp\u003e10 (22.22)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e2.5077 \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.113\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eTotal Number of Infections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2.2 (2)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1.57 (1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.0574 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eTransport Costs to Health Facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e6813.33 (5374.35)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e4434.78 (2978.83)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.0069 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 0px;\"\u003e\n \u003cp\u003eDistance to Health Centers (KMs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 166px;\"\u003e\n \u003cp\u003e4.79 (3.32)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 143px;\"\u003e\n \u003cp\u003e5.28 (3.62)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 122px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 81px;\"\u003e\n \u003cp\u003e0.2226\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003cp\u003eTable 4: Multivariate Analyses: Factors Independently Associated with Emotional Problems in CALWH With Viral Non-Suppression\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"504\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eStudy Variable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOdds ratio \u0026nbsp;\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e95% Confidence Interval\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003eFood Security\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e0.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.004 \u0026ndash; 0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003eCaregiver employment\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eStatus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e5.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.29 \u0026ndash; 101.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.255\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003eTotal Number of Infections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e0.47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.25 \u0026ndash; 0.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.023\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003eAdherence to ART\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.11 \u0026ndash; 4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.661\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003eSuicide Risk Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e1.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.83 \u0026ndash; 2.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.221\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003ePTSD Scores\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e1.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e1.19 \u0026ndash; 1.49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003eTransport Costs to Health Facilities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e1.00 \u0026ndash; 1.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003eDistance to Health Centers (KMs)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.59 \u0026ndash; 1.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.186\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003ePerceived Social support from parents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e0.98\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.94 \u0026ndash; 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.486\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 24.3534%;\"\u003e\n \u003cp\u003ePerceived Social Support from friends\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.7672%;\"\u003e\n \u003cp\u003e0.96\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 43.319%;\"\u003e\n \u003cp\u003e0.90 \u0026ndash; 3.86\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10.5603%;\"\u003e\n \u003cp\u003e0.210\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examined the prevalence and factors associated with emotional problems among children and adolescents living with HIV (CALWH) with viral non-suppression. The findings revealed a high prevalence of emotional problems, affecting 61.97% of participants, with significant anxiety symptoms present in all cases, making excessive anxiety the most common emotional problem in this population. This estimate is notably higher than those reported in previous studies. For example, the CHAKA study in Uganda, which assessed 1,339 children and adolescents using the Child and Adolescent Symptom Inventory-5 (CASI-5), found a 9% prevalence of anxiety disorders (33). Similarly, a study in Botswana using the Mini-International Neuropsychiatric Interview-Kid Screen (MINI-KID) reported an 18% prevalence among 743 adolescents (34). A recent systematic review and meta-analysis of psychiatric disorders among HIV-positive adolescents in sub-Saharan Africa reported a 26% prevalence of anxiety disorders (35).\u003c/p\u003e\n\u003cp\u003eThe prevalence of significant depression symptoms among affected participants was 45.45%, with all cases presenting comorbid considerable anxiety symptoms. This estimate aligns with findings by Kemigisha et al., who reported a 45% prevalence of depression among adolescents with HIV in Southwestern Uganda (36). However, studies from other African regions show much lower rates. The PopART trial in South Africa and Zambia reported a 27.6% prevalence of depression (37), while a systematic review and meta-analysis of psychiatric disorders among adolescents living with HIV in Sub-Saharan Africa found a pooled prevalence of 24% (35). Globally, depression affects an estimated 26.07% of adolescents with HIV (38). The discrepancy between our study and the CHAKA study may be due to the post-conflict setting of our study, where children faced greater stressors compared to non-conflict regions like those in the CHAKA study. Additionally, anxiety symptoms identified by screening tools tend to be more prevalent than full-blown anxiety disorders assessed by diagnostic tools.\u003c/p\u003e\n\u003cp\u003eOur study assessed depression and anxiety using the Revised Child Anxiety and Depression Scale (RCADS-25), a screening tool for depression and anxiety. Participants who scored above the established cut-off points were classified as having significant symptoms of anxiety or depression. While the high prevalence reported in this study is concerning, it is important to account for methodological differences, such as the use of screening tools versus diagnostic assessments, when interpreting these findings.\u003c/p\u003e\n\u003cp\u003eThe comorbidity between depression and anxiety is well-documented, as prior research indicates that depression in children and adolescents often co-occurs with anxiety, sharing common risk factors and distinct neurostructural patterns \u0026nbsp;\u0026nbsp;(39\u0026ndash;41). Our study extends these findings to children and adolescents living with HIV (CALWH) with unsuppressed viral loads, showing that depression in this population is almost invariably accompanied by anxiety. We recommend that screening for both anxiety and depression be integrated into HIV care packages, as these common mental health disorders have been shown to negatively impact HIV treatment outcomes, as demonstrated in studies from Uganda (42), South Africa (43), and Mozambique (44).\u003c/p\u003e\n\u003cp\u003eThe second major finding in this study was that these emotional problems were independently associated with food insecurity, post-traumatic stress symptoms, and higher transport costs to the health facilities.\u0026nbsp;Previous research indicates that food insecurity can lead to various mental health issues, including depressive symptoms and anxiety, among young people living with HIV(45). Studies in both high-income and low-income countries have linked food insecurity to emotional problems. A systematic review of 23 peer-reviewed articles from developed countries showed that household food insecurity was associated with emotional problems(46).\u0026nbsp;A study of young people in Eastern Zambia found that nearly half of the participants experienced severe food insecurity, which was significantly associated with higher levels of depressive symptoms (8).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding post-traumatic stress symptoms, previous studies have documented that children with chronic illnesses are at an increased risk of developing post-traumatic stress disorder (PTSD) due to various factors, including subjective experiences of trauma, family dysfunctions and low support, and parental traumas and poor mental health \u0026nbsp; (47\u0026ndash;49). In our study population, some of the challenges reported by the CALWH in a qualitative study included inadequate care and negative attitudes from their parents, who sometimes view them as outcasts (50). Such attitudes from family members are detrimental, as they reinforce feelings of worthlessness and hopelessness.\u003c/p\u003e\n\u003cp\u003eTransport costs have been recognized as a significant contributor to the economic burden faced by caregivers of children living with HIV (51). In this study, transport costs were independently associated with emotional problems, despite CALWH with emotional problems residing closer to health facilities compared to those without such issues. Additionally, CALWH with emotional problems reported a higher frequency of recurrent infections than their counterparts without emotional problems. We hypothesize that the elevated transport costs stem from more frequent visits to healthcare facilities required to manage recurrent infections and comorbid conditions. This highlights the interconnected nature of emotional problems, health complications, and economic burden in this population.\u003c/p\u003e\n\u003cp\u003eAn important negative finding in this study is the lack of association between emotional problems and gender. Previous research on this topic has shown mixed results. Two South African studies using the Child Behavior Checklist (CBCL) found that emotional problems were similarly distributed across genders among children and adolescents living with HIV (52,53). In contrast, a systematic review by Ayano et al. reported higher rates of depression among female adolescents, while studies in Mozambique and South Africa observed higher prevalences of anxiety in females compared to males \u0026nbsp; (38,54,55). These findings highlight the importance of adopting a gender-neutral approach when screening for and addressing emotional problems among children and adolescents living with HIV (CALWH), ensuring that interventions are inclusive and equitable for all genders.\u003c/p\u003e\n\u003cp\u003eAnother notable negative finding was that CALWH with emotional problems had a higher risk of suicide, although this association did not reach statistical significance in multivariate analyses. Previous studies have shown that CALWH in Uganda are at increased risk for suicidal ideation (56), a disheartening trend also observed among children in Rwanda and South Africa (57) (58). These findings emphasize the urgent need to integrate routine suicide screening into HIV care for CALWH.\u003c/p\u003e\n\u003cp\u003eAdditionally, CALWH who were adherent to ART were less likely to experience emotional problems, though this association also did not achieve statistical significance. Emotional problems, including depression, anxiety, and emotional unawareness, are known to interfere significantly with adherence to antiretroviral therapy (ART) in this population. Addressing these emotional challenges remains crucial for improving HIV treatment outcomes.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eLimitations of the Study\u003c/h2\u003e\n\u003cp\u003eThis study has some limitations that should be considered when interpreting the findings. Firstly, while the Revised Child Anxiety and Depression Scale (RCADS-25) and other tools used have strong psychometric properties, they have not been validated explicitly for CALWH in Uganda. Cultural differences in the expression of emotional distress may affect the accuracy of these measures in this context. Secondly, although the study was adequately powered for most analyses, the sample size may have been insufficient to detect subtle associations in subgroup analyses, particularly for certain sociodemographic and psychosocial variables. Lastly, the study was conducted in a single rural, post-conflict district. While Kitgum reflects similar contexts in northern Uganda, the findings may not be generalizable to urban areas or regions with differing sociocultural and healthcare dynamics.\u003c/p\u003e\n\u003cp\u003eDespite these limitations, this study provides important insights into the emotional health challenges of CALWH in rural Uganda. It underscores the need for integrated mental health care within HIV treatment programs. Screening for mental health conditions should be a routine component of HIV care to facilitate early identification. Interventions such as group support psychotherapy(GSP) can support caregivers of CALWH and be adapted to address the emotional problems of CALWH. To strengthen these findings, future research should explore longitudinal designs, larger and more diverse samples, and use culturally validated tools.\u0026nbsp;\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study underscores the substantial burden of emotional problems among children and adolescents living with HIV (CALWH) who experience viral non-suppression in rural northern Uganda. These findings reveal a complex interplay between psychological challenges, such as depression and anxiety, and socio-economic factors, including poverty and food insecurity. The association between emotional distress and these hardships highlights the multidimensional vulnerabilities faced by this population, which extend beyond the clinical management of HIV. \u003c/p\u003e\n\u003cp\u003eBy shedding light on the prevalence and drivers of emotional problems in CALWH, the study emphasizes the need for integrated care models that address both mental health and socio-economic determinants of well-being. These insights underscore the urgency of incorporating mental health support into HIV treatment programs and ensuring access to resources that mitigate structural barriers. Addressing these intertwined challenges is critical for improving treatment outcomes, enhancing quality of life, and fostering resilience among this vulnerable group.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: This work is part of a research project funded by several small grants from CRI Foundation through \u0026nbsp; FIDELITY Charitable International Grants; Grant ID Numbers: 13624790, 12977146, 14789811, 15884099, 16583402\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUnaids. 2024 global AIDS report \u0026mdash; The Urgency of Now: AIDS at a Crossroads [Internet]. 2024. Available from: http://www.wipo.int/\u003c/li\u003e\n\u003cli\u003eSlogrove AL, Mahy M, Armstrong A, Davies M. Living and dying to be counted: What we know about the epidemiology of the global adolescent HIV epidemic. J Int AIDS Soc. 2017 May 16;20(S3). \u003c/li\u003e\n\u003cli\u003eDavies MA, Gibb D, Turkova A. 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J Affect Disord. 2019 Feb;245:82\u0026ndash;90. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"MRC/UVRI/LSHTM Uganda Research Unit","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Children and adolescents, HIV, Unsuppressed viral load, Depression, Anxiety, Uganda problems","lastPublishedDoi":"10.21203/rs.3.rs-6231690/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6231690/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction: \u003c/strong\u003eChildren and adolescents living with HIV(CALWH) face significant mental health challenges, such as depression and anxiety, which negatively impact their HIV treatment outcomes. This study investigated the prevalence and factors associated with emotional problems among children and adolescents with unsuppressed viral loads in Northern Uganda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e \u003c/strong\u003e\u003c/em\u003eIn 2021, 121 dyads of caregivers and CALWH (10 to 18 years) with unsuppressed viral loads were recruited from five community-based HIV clinics in Kitgum district. They were assessed for emotional problems using the Revised Child Anxiety and Depression Scale (RCADS-25), the Patterson Suicide Risk Assessment Tool and the Clinician-administered Post-traumatic Stress Disorder Scale for Children and Adolescents (CAPS-CA). Bivariate and multivariate analysis of the data was carried out using STATA version 18.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eEmotional problems were observed in 61.97% of participants. Among these, depression was present in 45.45% of individuals, and all participants diagnosed with depression also exhibited significant comorbid anxiety symptoms. Notably, 16.52% of participants experienced anxiety without comorbid depression. Factors independently associated with emotional problems included food insecurity (p = 0.003; OR = 0.03), post-traumatic stress disorder (PTSD) (p \u0026lt; 0.0001; OR = 1.33), and high transportation costs to health facilities (p = 0.0069; OR = 1.00). However, no significant association was observed between emotional problems and gender (p = 0.94; χ² = 0.009).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003cem\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eThese results emphasize the importance of addressing underlying socio-economic and psychological factors to improve emotional well-being. Targeted interventions focused on reducing barriers to resources and providing mental health support are essential for fostering equitable mental health outcomes.\u003c/p\u003e","manuscriptTitle":"Prevalence and Factors Associated with Emotional Problems Among HIV-Positive Children and Adolescents with Viral Non-Suppression in Rural Northern Uganda.","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-18 04:31:03","doi":"10.21203/rs.3.rs-6231690/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"fbc2b14f-5a72-43bf-b793-2e3a05676c21","owner":[],"postedDate":"March 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":45718103,"name":"Psychiatry"}],"tags":[],"updatedAt":"2025-03-18T04:31:03+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-18 04:31:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6231690","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6231690","identity":"rs-6231690","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}