Julie Denison

Johns Hopkins University | JHU · Department of international health

The Evidence Project conducts systematic reviews and meta-analyses of HIV behavioral interventions, behavioral aspects of biomedical interventions, combination prevention strategies, modes of service delivery, and integrated programs in low- and middle-income countries. Here, we present the overall protocol for our reviews. For each topic, we condu...

While multi-level theories and frameworks have become a cornerstone in broader efforts to address HIV inequities, little is known regarding their application in adolescent and young adult (AYA) HIV research. To address this gap, we conducted a scoping review to assess the use and application of multi-level theories and frameworks in AYA HIV prevent...

Introduction Self-collected samples (SCS) for sexually transmitted infection (STI) testing have been shown to be feasible and acceptable in high-resource settings. However, few studies have assessed the acceptability of SCS for STI testing in a general population in low-resource settings. This study explored the acceptability of SCS among adults in...

The Project YES! clinic-based peer mentoring program was a randomized controlled trial (RCT) conducted among 276 youth from four HIV clinics to test the impact of the program on promoting HIV self-management and reducing internalized stigma among youth living with HIV (ages 15–24 years) in Ndola, Zambia. We conducted a qualitative sub-study involvi...

The COVID-19 pandemic and subsequent mitigation measures led to social disruption and negative economic shocks for a large proportion of Uganda's population. The social and economic consequences of COVID-19 on Ugandan men's sexual behaviours, including transactional sex relationships, are unclear. We conducted in-depth interviews between November 2...

Understanding treatment-seeking behavior is critical to the treatment and control of sexually transmitted infections (STIs), yet current data on STI treatment seeking in low-resource settings is rare. This population-based study aimed to describe STI treatment-seeking behavior and identify factors associated with seeking treatment at a clinic among...

Introduction: While disengagement from HIV care threatens the health of persons living with HIV (PLWH) and incidence-reduction targets, re-engagement is a critical step towards positive outcomes. Studies that establish a deeper understanding of successful return to clinical care among previously disengaged PLWH and the factors supporting re-engage...

Introduction: Self-collected samples (SCS) for sexually transmitted infection (STI) testing have been shown to be feasible and acceptable in high-resource settings. However, few studies have assessed the acceptability of SCS for STI testing in a general population in low-resource settings. This study explored the acceptability of SCS among adults i...

Understanding treatment-seeking behavior is critical to the treatment and control of sexually transmitted infections (STIs), yet current data on STI treatment-seeking in low-resource settings is scarce. This study aims to describe STI treatment-seeking behavior and identify factors associated with seeking treatment at a clinic among adults with STI...

Adolescent mental health (AMH) is a critical driver of HIV outcomes, but is often overlooked in HIV research and programming. The implementation science Exploration, Preparation, Implementation, Sustainment (EPIS) framework informed development of a questionnaire that was sent to a global alliance of adolescent HIV researchers, providers, and imple...

Adolescents and young adults (AYA) 13-24 years old make up a disproportionate 21% of new HIV diagnoses. Unfortunately, they are less likely to treat HIV effectively, with only 30% achieving viral suppression, limiting efforts to interrupt HIV transmission. Previous work with mindfulness-based stress reduction (MBSR) has shown promise for improving...

Introduction Rapid antiretroviral therapy (ART) initiation can improve patient outcomes such as viral suppression and prevent new infections. However, not everyone who can start ART does so immediately. Methods We conducted a qualitative study to inform interventions supporting rapid initiation in the ‘Test and Start’ era. We purposively sampled 2...

Background Little is known about youth-led approaches to addressing HIV-related outcomes among adolescents and young adults (AYA) living with HIV. In response, Project YES! hired and trained youth living with HIV as peer mentors (YPMs) in four HIV clinics in Ndola, Zambia to hold meetings with 276 15-24-year-olds living with HIV. Within this random...

Introduction Tracing patients lost to follow-up (LTFU) from HIV care is widely practiced, yet we have little knowledge of its causal effect on care engagement. In a prospective, Zambian cohort, we examined the effect of tracing on return to care within 2 years of LTFU. Methods We traced a stratified, random sample of LTFU patients who had received...

Background Safety protocols are an essential component of studies addressing violence and mental health but are rarely described in the published literature from Sub-Saharan Africa. We designed and implemented a safety protocol within Project YES! (Youth Engaging for Success), which enrolled 276 youth living with HIV (ages 15–24 years) in a randomi...

Objective How clinics structure the delivery of antiretroviral therapy (ART) services may influence patient adherence. We assessed the relationship between models of HIV care delivery and adherence as measured by medication possession ratio (MPR) among treatment‐experienced adults in Tanzania, Uganda and Zambia. Methods Eighteen clinics were group...

Little data exist on how 15-to-24-year-old perinatally infected youth living with HIV (p-YLHIV) learn their HIV status, and how those disclosure experiences may relate to current viral suppression (VS). Cross-sectional analyses were conducted using baseline data from a randomized controlled trial testing a peer mentoring program in Ndola, Zambia. A...

Introduction Adolescents and young adults (AYAs) living with HIV face unique challenges and have poorer health outcomes than adults with HIV. Project YES! was a youth-led initiative to promote HIV self-management and reduce stigma among AYAs in four Ndola, Zambia clinics. Clinic health care providers (HCPs) were involved in multiple intervention as...

We examined the relationship between past-year violence victimization and viral load (VL) failure among consecutively-sampled male and female adolescents and young adults, aged 15–24, in four HIV clinics in Ndola, Zambia. Measures of past-year physical violence, psychological abuse, and forced sex were adapted from the ICAST-C and WHO Multi-Country...

Achieving the 95-95-95 UNAIDS targets requires meeting the needs of adolescents, however we lack evidenced-based approaches to improving adolescent adherence to antiretroviral therapy (ART), increasing viral suppression, and supporting general wellbeing. We developed Family Connections as a group intervention for adolescents and their adult caregiv...

Emerging data show associations between violence victimisation and negative HIV outcomes among youth in sub-Saharan Africa. We conducted in-depth interviews with adolescents and young adults living with HIV (aged 15–24 years) in Ndola, Zambia, to better understand this relationship. We purposively selected 41 youth (24 females, 17 males) with varie...

Background: Dynamic movement of patients in and out of HIV care is prevalent, but there is limited information on patterns of patient re-engagement or predictors of return to guide HIV programs to better support patient engagement. Methods: From a probability-based sample of lost to follow-up, adult patients traced by peer educators from 31 Zamb...

Infants born to HIV-infected mothers are more likely to be low birthweight (LBW) than other infants, a condition that is stigmatized in many settings worldwide, including sub-Saharan Africa. Few studies have characterized the social-cultural context and response to LBW stigma among mothers in sub-Saharan Africa or explored the views of women living...

Background HIV drug resistance (HIVDR) poses a threat to the HIV epidemic control in Zambia especially in sub-populations such as the 15–24 years where there is poor virological suppression. Understanding the prevalence and patterns of HIVDR in this population (15–24 years) will contribute to defining effective antiretroviral therapy (ART) regimens...

Background Little is known about violence against HIV-positive adolescents and young adults (AYA) in sub-Saharan Africa. This analysis examines experiences of violence victimization, and the perpetrators of this violence, among AYA living with HIV, aged 15–24 years, in Zambia. Methods We analyzed baseline data from 272 AYA (60.1% female, 71.0% per...

[This corrects the article DOI: 10.1371/journal.pone.0230703.].

Background Youth-led strategies remain untested in clinic-based programs to improve viral suppression (VS) and reduce stigma among HIV-positive adolescents and young adults (AYA) in sub-Saharan Africa. In response, Project YES! placed paid HIV-positive youth peer mentors (YPM) in four HIV clinics in Ndola, Zambia including a Children’s Hospital (pe...

Arthur Davison Children's Hospital Pathology Laboratory’s Standard Operating Procedures used to test Project YES! (Youth Engaging for Success) HIV viral load and resistance testing.

Women in sub-Saharan Africa are disproportionately at risk for the dual epidemics of intimate partner violence (IPV) and HIV. Little is known about how specific violence profiles affect women’s HIV risk, limiting effective intervention. We analysed couples’ data from the Zambia Demographic and Health Survey 2013–2014 to evaluate relationships among...

Background Different tools exist for assessing risk of bias of intervention studies for systematic reviews. We present a tool for assessing risk of bias across both randomized and non-randomized study designs. The tool was developed by the Evidence Project, which conducts systematic reviews and meta-analyses of behavioral interventions for HIV in l...

Background Understanding and meeting the reproductive health needs of adolescents living with HIV (ALHIV) is a growing concern since advances in antiretroviral therapy mean that many ALHIV are now living into adulthood and starting to have sex. Methods We conducted a mixed-methods study in the Copperbelt Province of Zambia to advance our understan...

Little is known about adherence to antiretroviral therapy (ART) among adolescents in sub-Saharan Africa, where the majority of the world’s HIV-positive adolescents reside. We assessed individual, household, and HIV self-management characteristics associated with a 48-hour treatment gap in the preceding 3 months, and a pharmacy medication possession...

Background: Organization of HIV care and treatment services, including clinic staffing and services, may shape clinical and financial outcomes, yet there has been little attempt to describe different models of HIV care in sub-Saharan Africa (SSA). Information about the relative benefits and drawbacks of different models could inform the scale-up o...

Informal care receipt is associated with health outcomes among people living with HIV. Less is known about how caregivers’ own social support may affect their care recipient’s health. We examined associations between network characteristics of informal caregivers and HIV viral suppression among former or current drug using care recipients. We analy...

Background The importance of youth engagement in designing, implementing and evaluating programs has garnered more attention as international initiatives seek to address the HIV crisis among this population. Adolescents, however, are not often included in HIV implementation science research and have not had opportunities to contribute to the develo...

What is already known about this topic? Monitoring prevalence of advanced human immunodeficiency virus (HIV) disease (i.e., CD4+ T-cell count <200 cells/µL) among persons initiating antiretroviral therapy (ART) is important to help understand ART program outcomes, inform HIV prevention strategies, and forecast need for adjunctive therapies. What is...

The recognition and fulfilment of the sexual and reproductive health and rights (SRHR) of all individuals and couples affected by HIV, including HIV-serodiscordant couples, requires intervention strategies aimed at achieving safe and healthy pregnancies and preventing undesired pregnancies. Reducing risk of horizontal and vertical transmission and...

Research suggests a syndemic of substance use, mental illness, and familial conflict is associated with poor HIV medical outcomes among African American persons living with HIV (PLHIV). Social support may facilitate positive health outcomes. This study explores psychosocial correlates of HIV medical outcomes, defined as undetectable viral load (UVL...

Traditional healers provide healthcare to a substantial proportion of people living with HIV infection (PLHIV) in high HIV burden countries in sub-Saharan Africa. However, the impact on the health of retained patients visiting traditional healers is unknown. In 2011, a study to asses adherence to anti-retroviral therapy (ART) performed in 18 purpos...

Background: Adolescents living with HIV (ALHIV) experience less favorable antiretroviral therapy (ART) outcomes than other age groups. First-line treatment failure complicates ART management as second-line regimens can be costlier and have greater pill burdens. Understanding predictors of switching ART regimens and adherence among adolescents on s...

Background: Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. Behavioral interventions, involving counseling...

Objectives: To identify the reasons patients miss taking their antiretroviral therapy (ART) and the proportion who miss their ART because of symptoms; and to explore the association between symptoms and incomplete adherence. Methods: Secondary analysis of data collected during a cross-sectional study that examined ART adherence among adults from...

Equitable access to antiretroviral therapy (ART) for men and women with human immunodeficiency virus (HIV) infection is a principle endorsed by most countries and funding bodies, including the U.S. President's Emergency Plan for AIDS (acquired immunodeficiency syndrome) Relief (PEPFAR) (1). To evaluate gender equity in ART access among adults (defi...

Background: Worldwide, HIV-related mortality among adolescents living with HIV (ALHIV) increased by 50% from 2005 to 2012, attributed in part to incomplete ART adherence in this population. Methods: We conducted a cross-sectional study in 2012-2013 among ALHIV (15-19 years) attending three HIV clinics in Zambia. Participants´ self-report of missin...

Background: HIV/AIDS is the main cause of mortality among adolescents in Sub-Saharan Africa. Understanding baseline predictors of switching to second-line antiretroviral therapy (ART) and adherence among adolescents who have switched may help prevent poor treatment outcomes. Methods: In 2012-2013, a quantitative survey was administered to 309 eli...

Objective: To explore the role of informal caregivers in adherence, we compared adherence reports by caregivers to those of care recipients. We identified individual-level and relationship factors associated with agreement between caregivers' reports of recipients' adherence and assessed viral suppression.. Methods: Participants were care recipien...

To characterize antiretroviral therapy (ART) adherence across different programmes and examine the relationship between individual and programme characteristics and incomplete adherence among ART clients in sub-Saharan Africa. A cross-sectional study. Systematically selected ART clients (≥18 years; on ART ≥6 months) attending 18 facilities in three...

Worldwide, HIV-related mortality among adolescents living with HIV (ALHIV) increased by 50% from 2005 to 2012 and is attributed in part to a lack of support for adolescent retention to care and adherence to antiretroviral therapy (ART). This vulnerability reinforces the need to better understand incomplete ART adherence among ALHIV, particularly in...

Although scale-up of antiretroviral therapy (ART) since 2005 has contributed to declines of about 30% in the global annual number of human immunodeficiency (HIV)-related deaths and declines in global HIV incidence, estimated annual HIV-related deaths among adolescents have increased by about 50% and estimated adolescent HIV incidence has been relat...

Objectives We assessed retention and predictors of attrition (recorded death or loss to follow-up) in antiretroviral treatment (ART) clinics in Tanzania, Uganda and Zambia.Methods We conducted a retrospective cohort study among adults (≥18 years) starting ART during 2003–2010. We purposefully selected six health facilities per country and randomly...

Evaluation of differences between human immunodeficiency virus (HIV)-infected men and women in antiretroviral therapy (ART) enrollment characteristics and outcomes might identify opportunities to improve ART program patient outcomes and prevention impact. During September 2008-February 2012, retrospective cohort studies to estimate attrition of enr...

A cross-sectional survey among 550 randomly selected 16–19-year-olds in Ndola, Zambia, assessed the influence of individual (e.g., HIV knowledge), relational (e.g., discussed HIV testing with family), and environmental factors (e.g., distance) on adolescents’ use of HIV counseling and testing. A multivariable logistic regression analysis comparing...

Despite efforts to promote HIV counseling and testing (HCT) - among couples, few couples know their own or their partners' HIV status. We assessed trends in HCT uptake among married individuals in Rakai district, southwestern Uganda. We analysed data for 21,798 married individuals aged 15-49 years who were enrolled into the Rakai Community Cohort S...

Contraception services can help meet the family planning goals of women living with HIV as well as prevent mother-to-child transmission. Due to the increased availability of antiretroviral therapy, survival has improved for people living with HIV, and more HIV-positive women may desire to have a child or another child. This review examines behavior...

Background: Voluntary counseling and testing (VCT) continues to play a critical role in HIV prevention, care and treatment. In recent years, different modalities of VCT have been implemented, including clinic-, mobile- and home-based testing and counseling. This review assesses the effects of all VCT types on HIV-related risk behaviors in low- and...

To examine the relationship between condom social marketing programmes and condom use. Standard systematic review and meta-analysis methods were followed. The review included studies of interventions in which condoms were sold, in which a local brand name(s) was developed for condoms, and in which condoms were marketed through a promotional campaig...

Restless Development's youth-led model places trained Volunteer Peer Educators (VPEs), aged 18-25 years, in schools to teach HIV prevention and reproductive health (RH). VPEs also run youth centers, extracurricular and community-based activities. This evaluation assesses (i) program effects on students' HIV/RH knowledge, attitudes and behaviors usi...

This is the protocol for a review and there is no abstract. The objectives are as follows: The primary objective of this review is to systematically review the literature examining the effectiveness of VCT in changing HIV-related risk behaviors in developing countries across various populations. This review will also compare the effectiveness of th...

This chapter provides a brief overview of how HIV testing and counseling evolved and the different purposes it serves. The first licensed test for HIV became available in 1985, 4 years after the initial Morbidity and Mortality Weekly Report on the epidemic that described cases of Pneumocystis carina pneumonia in Los Angeles. In this context, the HI...

Background: Students Partnership Worldwide (SPW)/Zambia teaches 5th -12th graders HIV prevention and reproductive health (RH) by placing youth who have completed their secondary education as peer educators in schools. Purpose: To evaluate the associations between SPW program exposure and HIV and RH knowledge, attitudes and behaviors. Significan...

This study examined how individual, relational and environmental factors related to adolescent demand for HIV voluntary counseling and testing (VCT). A cross-sectional survey among randomly selected 16-19-year-olds in Ndola, Zambia, covered individual (e.g., HIV knowledge), environmental (e.g., distance), and relational factors (e.g., discussed VCT...

The effectiveness of HIV voluntary counseling and testing (VCT) in reducing HIV risk behaviors in developing countries was assessed using meta-analytic methods. A standardized protocol was used for searching, acquiring, and extracting study data and meta-analyzing the results. Seven studies met the inclusion criteria. VCT recipients were significan...

This study explored how adolescents involve their families, friends and sex partners when making decisions about seeking HIV voluntary counseling and testing (VCT) and disclosing their HIV-status. The study is based on 40 qualitative in-depth interviews with 16 to 19 year olds who knew their HIV status in Ndola, Zambia. The findings show that: a) a...

This review systematically examined the effectiveness of 24 mass media interventions on changing human immunodeficiency virus (HIV)-related knowledge, attitudes and behaviors. The intervention studies were published from 1990 through 2004, reported data from developing countries and compared outcomes using (i) pre- and post-intervention data, (ii)...

A comprehensive approach to preventing HIV infection in infants has been recommended, including: (a) preventing HIV in young women, (b) reducing unintended pregnancies among HIV-infected women, (c) preventing vertical transmission (PMTCT), and (d) providing care, treatment, and support to HIV-infected women and their families. Most attention has be...

To examine the application of the transtheoretical model (TM) to women's experiences of ending intimate partner violence (IPV). Qualitative interviews were conducted with 23 abused women. Women use 7 traditional processes of change. Women in early stages of change use cognitive processes. Women in later stages use behavioral processes. Consciousnes...

Why is it that interventions at the individual level, such as health education and counseling, have become so dominant in the effort to slow the transmission of HIV and AIDS? Are interventions that include a focus on environmental changes perhaps more cost-effective than those that rely only on individual persuasion? Moreover, what can be done to f...