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Variation and differential selection pressures on Tat genes have been shown to alter the biological function of the protein, resulting in pathological consequences in a number of organs including the brain. We evaluated the impact of genetic variation and selection pressure on 147 HIV-1 subtype C Tat exon 1 sequences from monocyte-depleted peripheral lymphocytes on clinical diagnosis of neurocognitive impairment. Genetic analyses identified two signature amino acid residues, lysine at codon 24 (24K) with a frequency of 43.4% and arginine at codon 29 (29R) with a frequency of 34.0% in individuals with HIV-associated neurocognitive impairment. The analyses also revealed two signature residues, asparagine, 24 N (31.9%), and histidine, 29H (21.3%), in individuals without neurocognitive impairment. Both codons, 24 and 29, were associated with high entropy but only codon 29 was under positive selection. The presence of signature K24 increased by 2.08 times the risk of neurocognitive impairment, 3.15 times higher proviral load, and 69% lower absolute CD4 T-cell count compared to those without the signature. The results support a linkage between HIV-1 C Tat N24K polymorphism, proviral load, immunosuppression, and neurocognitive impairment. The signature may induce more neurotoxic effects, which contributes to establishment and severity of HIV-associated neurocognitive impairment.

There is wide variation in the reported prevalence of cognitive impairment in people with HIV (PWH). Part of this variation may be attributable to different studies using different methods of combining neuropsychological test scores to classify participants as either cognitively impaired or unimpaired. Our aim was to determine, in a South African cohort of PWH (N = 148), (a) how much variation in reported rates was due to method used to define cognitive impairment and (b) which method correlated best with MRI biomarkers of HIV-related brain pathology. Participants completed detailed neuropsychological assessment and underwent 3 T structural MRI and diffusion tensor imaging (DTI). We used the neuropsychological data to investigate 20 different methods of determining HIV-associated cognitive impairment. We used the neuroimaging data to obtain volumes for cortical and subcortical grey matter and total white matter and DTI metrics for several white matter tracts. Applying each of the 20 methods to the cognitive dataset resulted in a wide variation (20–97%) in estimated rates of impairment. Logistic regression models showed no method was associated with HIV-related neuroimaging abnormalities as measured by structural volumes or DTI metrics. We conclude that for the population from which this sample was drawn, much of the variation in reported rates of cognitive impairment in PWH is due to the method of classification used, and that none of these methods accurately reflects biological effects of HIV in the brain. We suggest that defining HIV-associated cognitive impairment using neuropsychological test performance only is insufficient; pre-morbid functioning, co-morbidities, cognitive symptoms, and functional impairment should always be considered.

The authors investigated South African psychiatry residents’ satisfaction with their training, physical, and mental health to inform the development of a strategy to improve the quality and experiences of training. A cross-sectional online survey was undertaken to assess the factors affecting residents’ satisfaction with their current training program. The authors conducted a comparative analysis of residents across the training institutions in South Africa. Of 179 psychiatry residents in the country, 70 responses were received (39.1% response rate). Most were satisfied with the overall quality of their training, various aspects of training, and access to training resources. However, significant differences across universities were identified with regard to residents’ perception of the quality of their training, quality of their experiences, access to training resources, quality of supervision, and clinical workload. More than a quarter were dissatisfied with their mental and/or physical health. The top four factors contributing to stress were all training-related. While most residents were satisfied with their specialist training, institutional differences in access to training and training resources, quality of training, and availability of quality supervision were evident and need to be addressed to ensure equitable training. There is a need to actively address staff shortages not only for clinical cover during protected academic time but also to meet training needs. A centralized examination process should remain in place to ensure that there is a national standard. Workplace-based assessments could facilitate standardization across institutions, should these assessments be standardized and accompanied by rigorous training of supervisors.

BACKGROUND: Tobacco use is the leading cause of preventable death worldwide, and prevalence rates are high among people living with HIV (PLWH), particularly in men. Depression is also common among PLWH, especially among smokers, who may use tobacco to manage mood. Although HIV and depression have been linked to functional impairment and poor health-related quality of life (HRQOL), little research has examined the degree to which smoking impacts these relationships in low and middle-income countries with high HIV burden. METHOD: Participants (N = 289) were people living with HIV (PLWH) who were being assessed for inclusion in a study targeting depression as a barrier to HIV medication adherence. Linear regression models measured the effect of gender on tobacco use (assessed by the WHO-ASSIST) and on each of the five HRQOL functional impairment domains (assessed by the SF-21). Separate multivariable regression models examined the relationships between habitual tobacco use, defined as daily, almost daily, or weekly use, and the HRQOL domains. RESULTS: The prevalence of habitual tobacco use was 23.9% (48.1% among men, 15.5% among women). Habitual tobacco use was associated with decreased cognitive functioning for the whole sample (B = −8.99, p < .05) and with lower levels of pain-related impairment for men (B = 18.1, p < .05). Although men reported more tobacco use (B = 8.50, p < .001), they reported less pain-related limitations than women (B = 8.70, p < .05). CONCLUSIONS: In our sample, men reported higher rates of habitual tobacco use than women. Smoking was associated with cognitive impairment and with less pain-related impairment among men. Future smoking cessation treatments tailored to PLWH who have symptoms of depression may benefit from strategies that consider pain management as a pathway to habitual smoking and recognize that motivations for use may differ by gender.

Driving ability can be diminished amongst people with HIV with associated neurocognitive impairment (NCI). We explore the relationship between HIV status, NCI and driving ability in professional truck drivers. Forty male professional drivers (20 HIV-positive; mean age = 39.20 ± 7.05) completed a neuropsychological test battery, two driving simulator tasks that assessed driving ability, and a driving history and habits questionnaire. A higher proportion of HIV-positive drivers exhibited impaired overall cognitive performance (p ≤ 0.001). Overall, drivers with NCI (defined as z ≤ 1.00) were more likely than those without NCI to crash (p = 0.002). There were no significant between-group (HIV-positive versus HIV-negative) differences with regard to self-reported on-road driving events. Professional drivers with NCI, as measured on a driving simulator, are at increased risk of making driving errors under high-risk conditions compared to their neurocognitively normal counterparts. These data should inform driver health management with regard to annual medical screening and surveillance.La capacidad de conducción puede verse disminuida entre las personas con VIH con deterioro neurocognitivo asociado (neurocognitive impairment, NCI). Exploramos la relación entre la situación frente al VIH, el NCI y la capacidad de conducción en conductores profesionales de camiones. Cuarenta conductores profesionales masculinos (20 seropositivos, edad media = 39.20 ± 7.05) completaron una batería de pruebas neuropsicológicas, dos tareas de simulador de conducción que evaluaron la capacidad de conducción y un cuestionario de hábitos y antecedentes de conducción. Una mayor proporción de conductores VIH positivos exhibió un desempeño cognitivo general deficiente (p ≤ 0.001). En general, los conductores con NCI (definido como z ≤ 1.00) tenían más probabilidades de chocar que aquellos sin NCI (p = 0.002). No hubo diferencias significativas entre los grupos (VIH positivo frente a VIH negativo) con respecto a los eventos autoinformados de conducción en carretera. Los conductores profesionales con NCI, según lo medido en un simulador de conducción, tienen un mayor riesgo de cometer errores de conducción en condiciones de alto riesgo en comparación con sus homólogos neurocognitivamente normales. Estos datos deberían informar a la gestión de la salud del conductor en lo que respecta a la vigilancia y los exámenes médicos anuales.

South Africa (SA) has the most people living with HIV/AIDS (PLWH) globally and prevalent alcohol use. Beliefs that mixing alcohol and antiretroviral therapy (ART) can lead to adverse reactions may promote ART nonadherence. Healthcare providers (n = 11) and patients (n = 19) recruited from primary HIV and substance use care in SA described their messages, beliefs, and behaviors around simultaneous use of alcohol and ART. Transcripts were analyzed using thematic analysis: (1) most providers indicated a message shift to reflect harm reduction principles: PLWH should manage alcohol use but not let it interfere with taking ART; however, (2) patients recalled conflicting messages from their providers and some displayed interactive toxicity beliefs and behaviors. Despite progress demonstrated by 2016 national adherence guidelines and shifted provider messaging, interactive toxicity beliefs remain a barrier to ART adherence. Results have implications for the adaptation of adherence counseling to minimize the impact of alcohol use on HIV treatment.

Dysregulated expression of neuro-immune markers has previously been linked to HIV-associated neurocognitive impairment. We undertook an exploratory approach in a HIV clade-C cohort, investigating the association between eight immune markers and neurocognitive performance in 99 HIV+ and 51 HIV- participants. Markers were selected on preliminary and putative evidence of their link to key neuro-immune functions. Cognitive performance was established using a battery of tests sensitive to HIV-associated neurocognitive impairment, with domain-based scores utilized in analysis. The markers Thymidine phosphorylase (TYMP) and Neutrophil gelatinase-associated lipocalin (NGAL) were significantly higher while Matrix Metalloproteinase (MMP)9 was significantly lower in HIV+ participants. Our results further showed that in the HIV+ group, worse psychomotor processing speed was associated with higher TYMP and NGAL levels and worse motor function was associated with higher NGAL levels. Future studies should explore the underlying mechanisms of these markers in HIV-associated neurocognitive impairment. Graphical Abstract The association of peripheral immune markers with neurocognitive performance in South African HIV-positive patients.

Rapid maturation of major white matter pathways occurs in the first 2 years of life, indicating a critical neuronal developmental period. The impact of initiating antiretroviral therapy (ART) in children perinatally infected with HIV-1, after the age of 2 years on neurocognitive functioning and white matter development in adolescence has not been studied. Forty-six adolescents who initiated ART during the first 2 years of life ( 2 years) and 79 adolescents who initiated ART after 2 years of age ( 2 years), with perinatally acquired HIV were enrolled in the Cape Town Adolescent Antiretroviral Cohort. Adolescents completed a comprehensive neurocognitive battery testing a number of cognitive domains. Diffusion tensor imaging (DTI) was done to determine fractional anisotropy (FA), mean diffusivity (MD), axial diffusion (AD), and radial diffusion (RD) in a region of interest analysis. Neurocognitive performance was similar between adolescents who initiated ART 2 years or 2 years. There was a trend towards attention (p = .07) and working memory (p = .05) being poorer in the group who initiated ART 2 years. FA was lower in the 2-year group in the superior corona radiata (p = .03), and the external capsule (p = .04). MD was higher in the 2-year group in the cerebral peduncle (p = .02), the superior corona radiata (p = .01), and the superior fronto-occipital fasciculus (p = .03). RD was higher in the 2-year group in the superior corona radiata (p = .02), the cerebral peduncle (p = .01), and the superior fronto-occipital fasciculus (p = .01). However, the higher AD in the 2-year group in the superior corona radiata was not in the expected direction (p = .01). Initiation of ART after the neuronal development period of the second postnatal year is associated with white matter alterations on neuroimaging.

For women enrolled in prevention of mother-to-child transmission (PMTCT) programs, non-disclosure of their HIV status can be a significant barrier to sustained HIV care engagement. To explore decision-making surrounding HIV disclosure among HIV-infected pregnant women, we conducted repeated in-depth interviews during pregnancy and postpartum with 20 women recruited from a PMTCT clinic in Cape Town, South Africa. Three domains were examined using thematic analysis: (1) disclosure experiences, (2) challenges associated with partner disclosure, and (3) implications of nondisclosure. All women had disclosed to someone by the time of the baby’s birth, typically limiting their disclosure to trusted individuals. Only half of participants disclosed to the father of the child. Nondisclosure, particularly to partners, was a significant source of worry and stress. Women used pregnancy as an explanation for using medication and attending frequent clinic appointments, and recognized impending challenges in the postpartum period when this excuse would no longer apply. Results suggest that PMTCT programs have a key role to play in helping individuals to make decisions about HIV disclosure, and assisting patients to navigate the disclosure process, especially with partners.

Lay-counsellors in resource-limited settings convey critical HIV- and ART-information, and face challenges including limited training and variable application of counselling. This study explored lay-counsellors and Department of Health (DoH) perspectives on the utility of a multimedia adherence counselling program. Masivukeni, an mHealth application that provides scaffolding for delivering standardized ART counselling was used in a 3-year randomized control trail at two primary health care clinics in Cape Town, South Africa. In this programmatic and descriptive narrative report, we describe the application; lay-counsellors' response to open-ended questions regarding their experience with using Masivukeni; and perspectives of the City of Cape Town and Western Cape Government DoH, obtained through ongoing engagements and feedback sessions. Counsellors reported Masivukeni empowered them to provide high quality counselling. DoH indicated strong support for a future implementation study assessing feasibility for larger scale roll-out. Masivukeni has potential as a counselling tool in resource-limited settings.

Improving AIDS Care after Trauma (ImpACT), a coping intervention for HIV-infected women with sexual abuse histories, was evaluated for feasibility and potential efficacy in a public clinic in Cape Town, South Africa. Sixty-four participants were enrolled prior to starting antiretroviral therapy (ART). After completing baseline assessments, participants were randomly assigned to standard of care (SoC: three adherence counseling sessions) or ImpACT (SoC plus four individual and three group sessions). Participants completed assessments at 3 months (after individual sessions) and 6 months post-baseline. In exploratory analysis of primary outcomes, ImpACT participants, compared to SoC, reported greater reductions in avoidance and arousal symptoms of PTSD and greater increases in ART adherence motivation at 3 months. Clinically significant decreases in overall PTSD symptoms were also demonstrated at 3 months. These effects continued as trends at the 6-month assessment, in addition to increases in social/spiritual coping. In analysis of secondary outcomes, high levels of non-adherence to ART and poor care engagement were evident at 6 months, with no differences between study arms. A trauma-focused, culturally-adapted individual intervention delivered by a non-specialist in the HIV care setting is feasible and acceptable. Preliminary findings suggest ImpACT has potential to reduce PTSD symptoms and increase ART adherence motivation, but a more intensive intervention may be needed to improve and maintain care engagement among this population. Trial Registration: ClinicalTrials.gov NCT02223390.

We compared the diagnostic accuracy of two brief screening tools (the International HIV Dementia Scale (IHDS), and the IHDS combined with a novel self-report instrument, the HIV Cognitive Symptom Questionnaire (HCSQ)) with that of three brief neuropsychological screening batteries (a 2-, a 3-, and a 4-test battery, each consisting of standardized cognitive tests) in discriminating individuals with HIV-associated dementia (HAD) from those with milder forms of cognitive impairment. We analyzed data from 94 isiXhosa-speaking South African HIV-infected participants who were screened as part of a clinical trial evaluating adjunctive treatment in patients with moderate to severe HIV-associated cognitive impairment. A comprehensive neuropsychological battery diagnosed 53% (50/94) of the participants with HAD. We evaluated the sensitivity and specificity for the screening tools and screening batteries. The brief screening tool performed better compared to the brief neuropsychology battery. The IHDS-HCSQ combination delivered 94% sensitivity and 63% specificity for HAD compared to the IHDS (74 and 70% at a cutoff of ≤8) which offers a viable and quick way to screen for HAD in people living with HIV. It is easy to administer, is time- and cost-efficient, and it appears to be a better option, for these purposes, than brief neuropsychology batteries. It is viable for use in clinical, research, and workplace settings when identification of HIV-infected people with severe cognitive impairment is required.

South African women have disproportionately high rates of both sexual trauma and HIV. To understand how sexual trauma impacts HIV care engagement, we conducted in-depth qualitative interviews with 15 HIV-infected women with sexual trauma histories, recruited from a public clinic in Cape Town. Interviews explored trauma narratives, coping behaviors and care engagement, and transcripts were analyzed using a constant comparison method. Participants reported multiple and complex traumas across their lifetimes. Sexual trauma hindered HIV care engagement, especially immediately following HIV diagnosis, and there were indications that sexual trauma may interfere with future care engagement, via traumatic stress symptoms including avoidance. Disclosure of sexual trauma was limited; no women had disclosed to an HIV provider. Routine screening for sexual trauma in HIV care settings may help to identify individuals at risk of poor care engagement. Efficacious treatments are needed to address the psychological and behavioral sequelae of trauma.

Author(s): Ng, Lauren C; Magidson, Jessica F; Hock, Rebecca S; Joska, John A; Fekadu, Abebaw; Hanlon, Charlotte; Galler, Janina R; Safren, Steven A; Borba, Christina PC; Fricchione, Gregory L; Henderson, David C

South Africa is experiencing a growing methamphetamine problem, and there is concern that methamphetamine use may accelerate HIV transmission. There has been little research on the HIV prevention needs of methamphetamine users receiving substance abuse treatment in South Africa. This study assessed the prevalence and correlates of HIV risk behaviors among 269 methamphetamine users entering substance abuse treatment in two clinics in Cape Town. The prevalence of sexual risk behaviors was high among sexually active participants: 34 % multiple partners, 26 % unprotected intercourse with a casual partner, and 24 % sex trading for money/methamphetamine. The strongest predictor of all sexual risk behaviors was concurrent other drug use. Over half had not been HIV tested in the past year, and 25 % had never been tested, although attitudes toward HIV testing were overwhelmingly positive. This population of primarily heterosexual, non-injecting methamphetamine users is a high-risk group in need of targeted HIV prevention interventions. Substance abuse treatment is an ideal setting in which to reach methamphetamine users for HIV services.

A range of factors contributes to white matter damage in vertically infected HIV-positive children. These may include combination antiretroviral treatment (cART) regimen, sociodemographic factors, nutritional-hematological status, HIV-relevant clinical variables, and cognitive functioning. We explored associations between a number of these factors and diffusion tensor imaging (DTI) measures in 50 cART-treated children aged 6 to 15 years. Fractional anisotropy (FA), mean diffusion (MD), radial diffusion (RD), and axial diffusion (AD) were derived from 48 cerebral white matter regions. Significant associations between a number of the clinical variables and white matter integrity were found. Decreased FA, a measure of neuronal damage, was associated with being on second-line cART, low hemoglobin, and younger age. Children with increased MD, a measure of neuronal damage, were younger, had reduced albumin and hemoglobin, and increased viral load. Decreased AD, a measure of axonal damage, was associated with increased viral load and total protein, decreased albumin and hemoglobin, younger age, poorer fronto-striatal cognition, and being on second-line cART. Increased RD, a measure of myelin loss, was associated with younger age, low current CD4 count, low albumin and hemoglobin, and higher viral load and total protein. The current findings underline the possible association of first-line treatment failure with white matter brain dysfunction in pediatric neuroHIV and the importance of examining the effects of HIV disease in the context of treatable clinical variables such as anemia and nutritional status.

Antenatal mental disorders compromise maternal and child health, and women who have experienced childhood trauma may be at increased risk for such disorders. One hypothesis is that early trauma leads to the development and use of maladaptive coping strategies as an adult, which in turn could predict mental health difficulties during stressful transitions such as pregnancy. To test this hypothesis, this study examined the relationship between childhood trauma and mental health (depression, PTSD) in a sample of 84 pregnant women seeking antenatal care in Cape Town, South Africa, and explored whether maladaptive coping mediated this relationship. The majority of women (62 %) met established criteria for antenatal depression and 30 % for antenatal PTSD; in addition, 40 % reported a history of childhood trauma. Childhood trauma, especially childhood sexual abuse and emotional abuse, was significantly associated with depression and PTSD. The relationships between childhood trauma and depression and PTSD were significantly mediated by maladaptive coping, even when adjusted for the woman's age, gestational age, and HIV status. Findings highlight the need for coping-based interventions to prevent and treat antenatal mental disorders among women with childhood trauma, particularly in high-trauma settings such as South Africa.

Given the high prevalence of HIV in South Africa and co-morbid mental disorders in people living with HIV/AIDs (PLWHA) we sought to validate a brief screening tool in primary HIV care. Methods: 366 PLWHA were recruited prior to combination anti-retroviral treatment (CART) initiation from two primary health HIV clinics. A mental health nurse administered a socio-demographic questionnaire and the Mini Neuropsychiatric Interview (MINI) and a lay counsellor administered the Substance and Mental Illness Symptom Screener (SAMISS). Results: Using the MINI, 17 % of participants were identified with either depression, anxiety disorders or adjustment disorder and 18 % with substance or alcohol abuse/dependence. The sensitivity and specificity of the SAMISS was 94 % (95 % CI: 88–98 %) and 58 % (95 % CI: 52–65 %) respectively, with the alcohol component (sensitivity: 94 %; specificity: 85 %) performing better than the mental illness component of the SAMISS (sensitivity: 97 %; specificity: 60 %). The specificity of the tool improved when the cut-off for the mental illness component was increased. Conclusion: The SAMISS may provide a useful first tier screening tool for common mental disorders in primary care for PLWHA.

HIV-associated dementia (HAD) is a serious neuropsychiatric disorder affecting people with AIDS. Host genotype may affect the pathogenesis of HIV in the central nervous system (CNS). One gene relevant to the individual variation in acquiring HAD may be Apolipoprotein E (ApoE). We aimed to investigate the relationship of ApoE genotype to neuropsychological function and white matter integrity of the corpus callosum in a region of interest a priori analysis of HIV-positive subjects with clade C HIV. Forty-five subjects underwent ApoE genotyping, neuropsychological testing, and diffusion tensor imaging (DTI). Subjects (n = 24) with at least one ε4 allele when compared to subjects with no ε4 allele (n = 19) had significantly decreased immediate and delayed recall on the Hopkins Verbal Learning test (p = 0.05) and significantly decreased fractional anisotrophy in the corpus callosum (p = 0.007). These data indicate that the ε4 allelic variant of ApoE is associated with memory impairment and white matter damage of the corpus callosum in HIV-positive subjects.

HIV infection is associated with an increased prevalence of common mental disorders and with the development of HIV associated neurological disorders (HAND). The aim of this research was to determine the reliability of lay adherence counsellors in the administration of the substance abuse and mental illness symptom screener (SAMISS) for common mental disorders and International HIV Dementia Scale (IHDS) for HAND in a South African sample of 269 people living with HIV/AIDS and on HAART in a primary healthcare setting. We used a cross-sectional design with each patient assessed by a mental health nurse and counsellor, 1 week apart. Reliability was fair for the SAMISS overall (κ = 0.39, CI95 0.29–0.49, P

It is not known whether the apolipoprotein E (ApoE)#x03B5;4 allelic variant is associated with human immunodeficiency virus (HIV)-associated dementia (HAD) in a South African population, where HIV clade C is predominant. ApoE genotyping was performed on 144 participants in a larger study of HIV-associated neurocognitive disorders (HAND). There was a lower frequency of the#x03B5;2 and#x03B5;3 alleles in the HIV-positive group, compared to a group of 300 community-based newborn infants. There were no differences in ApoE genotype across different categories of HAND. The#x03B5;4 allelic variant was less common in individuals with HAD than in those without HAD. These findings suggest that the#x03B5;4 allelic variant in HIV-positive individuals is not associated with the development of HAD in Southern Africa.

HIV-Associated Neurocognitive Disorders (HAND) exert an impact on everyday functions, including adherence. The prevalence of and risk factors for HAND in patients commencing anti-retroviral therapy in Southern Africa are unknown. Participants from primary care clinics in Cape Town, South Africa underwent detailed neuropsychological, neuropsychiatric, and neuromedical evaluation. Using the updated American Academy of Neurology (AAN) criteria, participants were classified into categories of HAND, and demographic and clinical risk factors for HIV-dementia (HIV-D) were assessed. The prevalence of mild neurocognitive disorder (MND) and HIV-D were 42.4 and 25.4%, respectively. There were significant associations between lower levels of education and older age with HIV-D, and a trend to association with HIV-D and lower CD4 count. In a regression model, a lower level of education and male gender were predictive of HIV-D. These findings suggest that HAND are highly prevalent in primary care settings in South Africa where clade C HIV is predominant.

Human immunodeficiency virus-associated neurocognitive disorders (HAND) occurs globally and across different genetic clades of the virus. However, few studies have examined HAND in South Africa, despite the prevalence of HIV in this region of the world, and the predominance of clade C. The present study examined the relationship between a number of demographic and clinical variables in a sample of 536 patients attending HIV clinics in South Africa. HAND was present in 23.5% of the sample and was associated with older age, a low educational level among those with post-traumatic stress disorder (PTSD) and alcohol abuse among those with many months since diagnosis. These results suggest that HAND is common among patients in South Africa, and is associated with clinical variables such as PTSD and alcohol abuse. This underlines the impact of HIV on the nervous system and the importance of screening for co morbid mental health conditions.

The field of psychiatric epidemiology has yielded several large and important studies of the prevalence of psychiatric disorders. These surveys have been enhanced by the inclusion of methodologies that reflect the needs for care of the population in question. Clinical studies of psychiatric disorders and unmet needs have focussed on identifying needs and correlating them with service evaluation and satisfaction measures. The association between prevalence, service use and unmet need requires review in order to establish whether there are trends and consistent findings.Peer-reviewed studies involving the assessment of need up to the present were included. These were of two broad groups: population-based studies and clinical studies. Studies based on outcome measures, review articles, and child psychiatry, old age, and intellectual disability samples were excluded. We conducted a search of MEDLINE and PSYCHINFO using the key words, "mental health needs","assessment of need", and "needs assessment". In addition, we hand-searched key journals and sought personal communication with researchers in the field.A total of 14 population studies and 19 clinical studies were retrieved. The percentage of the general population who reported at least one need for care ranged from 9.5% to 13.8%. The numbers of needs in psychiatric patients ranged from 3.3 to 8.6. Correlates of unmet need include: unemployment, single status, low quality of life and high disability scores, and the presence of certain psychiatric diagnoses, such as affective psychosis and personality disorders. Higher rates of met need and service satisfaction are correlated with a longer duration of service contact.The assessment of need to date has been established either by service use data to make inferences about unmet need, by asking limited guided questions about needs, or by using established needs assessment instruments. The high prevalence of psychiatric disorders and the weak correlation between disorder and unmet need require a combined approach towards service development.

Background: Maternal depression carries a major public health burden for mothers and their infants, yet there is a substantial treatment gap for this condition in low-resourced regions such as sub-Saharan Africa. To address this treatment gap, the strategy of “task sharing” has been proposed, involving the delivery of interventions by non-specialist health workers trained and supervised by specialists in routine healthcare delivery systems. Several psychological interventions have shown benefit in treating maternal depression, but few have been rigorously evaluated using a task sharing approach. The proposed trial will be the first randomised controlled trial (RCT) evaluating a task sharing model of delivering care for women with maternal depression in sub-Saharan Africa. The objective of this RCT is to determine the effectiveness and cost-effectiveness of a task sharing counseling intervention for maternal depression in South Africa. Methods/Design: The study is an individual-level two-arm RCT. A total of 420 depressed pregnant women will be recruited from two ante-natal clinics in a low-income township area of Cape Town, using the Edinburgh Postnatal Depression Scale to screen for depression; 210 women will be randomly allocated to each of the intervention and control arms. The intervention group will be given six sessions of basic counseling over a period of 3 to 4 months, provided by trained community health workers (CHW)s. The control group will receive three monthly phone calls from a CHW trained to conduct phone calls but not basic counseling. The primary outcome measure is the 17-Item Hamilton Depression Rating Scale (HDRS-17). The outcome measures will be applied at the baseline assessment, and at three follow-up points: 1 month before delivery, and 3 and 12 months after delivery. The primary analysis will be by intention-to-treat and secondary analyses will be on a per protocol population. The primary outcome measure will be analyzed using linear regression adjusting for baseline symptom severity measured using the HDRS-17. Discussion: The findings of this trial can provide policy makers with evidence regarding the effectiveness and cost-effectiveness of structured psychological interventions for maternal depression delivered by appropriately trained and supervised non-specialist CHWs in sub-Saharan Africa. Trial registration Clinical Trials (ClinicalTrials.gov): NCT01977326 , registered on 24/10/2013; Pan African Clinical Trials Registry ( http://www.pactr.org ): PACTR201403000676264 , registered on 11/10/2013.

Background A number of recently published randomized controlled trials conducted in developed countries have reported no advantage for assertive interventions over standard care models. One possible explanation could be that so-called "standard care" has become more comprehensive in recent years, incorporating some of the salient aspects of assertive models in its modus operandi. Our study represents the first randomised controlled trial assessing the effect of a modified assertive treatment service on readmission rates and other measures of outcome in a developing country. Methods High frequency service users were randomized into an intervention (n = 34) and a control (n = 26) group. The control group received standard community care and the active group an assertive intervention based on a modified version of the international model of assertive community treatment. Study visits were conducted at baseline and 12 months with demographic and illness information collected at visit 1 and readmission rates documented at study end. Symptomatology and functioning were measured at both visits using the PANSS, CDSS, ESRS, WHO-QOL and SOFAS. Results At 12 month follow-up subjects receiving the assertive intervention had significantly lower total PANSS (p = 0.02) as well as positive (p < 0.01) and general psychopathology (p = 0.01) subscales' scores. The mean SOFAS score was also significantly higher (p = 0.02) and the mean number of psychiatric admissions significantly lower (p < 0.01) in the intervention group. Conclusions Our results indicate that assertive interventions in a developing setting where standard community mental services are often under resourced can produce significant outcomes. Furthermore, these interventions need not be as expensive and comprehensive as international, first-world models in order to reduce inpatient days, improve psychopathology and overall levels of functioning in patients with severe mental illness.