Effects of cognitive behavioral therapy on people living with HIV and depression: A systematic review and meta-analysis

Preliminary Impact of Group-Based Interventions on Stigma, Mental Health, and Treatment Adherence Among Adolescents Living with Human Immunodeficiency Virus in Uganda

OBJECTIVE

To examine the preliminary impact of group cognitive behavioral therapy and multiple family group-based family strengthening to address HIV stigma and improve the mental health functioning of adolescents living with HIV in Uganda.

STUDY DESIGN

We analyzed data from the Suubi4Stigma study, a 2-year pilot randomized clinical trial that recruited adolescents living with HIV (10-14 years) and their caregivers (n = 89 dyads), from 9 health clinics. We fitted separate three-level mixed-effects linear regression models to test the effect of the interventions on adolescent outcomes at 3 and 6 months post intervention initiation.

RESULTS

The average age was 12.2 years and 56% of participants were females. Participants in the multiple family group-based family strengthening intervention reported lower levels of internalized stigma (mean difference = -0.008, 95% CI = -0.015, -0.001, P = .025) and depressive symptoms at 3 months (mean difference = -0.34, 95% CI = -0.53, -0.14, P < .001), compared with usual care. On the other hand, participants in the group cognitive behavioral therapy intervention reported lower levels of anticipated stigma at 3 months (mean difference = -0.039, 95% CI = -0.072, -0.006), P = .013) and improved self-concept at 6 months follow-up (mean difference = 0.04, 95% CI = 0.01, 0.01, P = .025).

CONCLUSION

Outcome trends from this pilot study provide compelling evidence to support testing the efficacy of these group-based interventions on a larger scale.

TRIAL REGISTRATION

The study is registered in the Clinical trials.gov database (Identifier #: NCT04528732).

Feasibility and Acceptability of Group-Based Stigma Reduction Interventions for Adolescents Living with HIV and Their Caregivers: The Suubi4Stigma Randomized Clinical Trial (2020-2022)

This study examined the feasibility and acceptability of two group-based interventions: group-cognitive behavioral therapy (G-CBT) and a family-strengthening intervention delivered via multiple family group (MFG-FS), to address HIV stigma among adolescents living with HIV (ALHIV) and their caregivers. A total of 147 adolescent -caregiver dyads from 9 health clinics situated within 7 political districts in Uganda were screened for eligibility. Of these, 89 dyads met the inclusion criteria and provided consent to participate in the study. Participants were randomized, at the clinic level, to one of three study conditions: Usual care, G-CBT or MFG-FS. The interventions were delivered over a 3-month period. While both adolescents and their caregivers attended the MFG-FS sessions, G-CBT sessions were only attended by adolescents. Data were collected at baseline, 3 and 6-months post intervention initiation. The retention rate was 94% over the study period. Across groups, intervention session attendance ranged between 85 and 92%, for all sessions. Fidelity of the intervention was between 85 and 100%, and both children and caregivers rated highly their satisfaction with the intervention sessions. ALHIV in Uganda, and most of sub-Saharan Africa, are still underrepresented in stigma reduction interventions. The Suubi4Stigma study was feasible and acceptable to adolescents and their caregivers -supporting testing the efficacy of the interventions in a larger trial.

Dose‒Response Effects of Patient Engagement on Anxiety and Depression in a Cognitive-Behavioral Intervention: Secondary Analysis of a Pilot Randomized Controlled Trial and a Clinical Controlled Trial

Understanding the dose‒response relationship between patient engagement in cognitive behavioral therapy (CBT) and health outcomes is critical for developing and implementing effective CBT programs. In studies of CBT interventions, patient engagement is measured only at a single time point, and outcomes are typically assessed before and after the intervention. Examination of the dose‒response relationship between patient engagement in CBT and outcomes is limited. It is unclear whether a dose‒response relationship exists between patient engagement in on-site CBT intervention and anxiety and depression in people living with HIV (PLWH). If present, does this dose‒response relationship occur early or later in the intervention? This study aimed to address this gap by examining the dose‒response relationships between patient engagement and anxiety and depression in CBT interventions among PLWH. Utilizing data from a pilot randomized trial (10 participants) and a clinical controlled trial (70 participants), our secondary analysis spans baseline, 3-month, and 6-month assessments. Both trials implemented the nurse-led CBT intervention. Cluster analysis identified two groups based on on-site attendance and WeChat activity. Patients with good adherence (6-10 times) of on-site attendance exhibited significantly lower anxiety and depression scores at 3 months (β = 1.220, P = 0.047; β = 1.270, P = 0.019), with no significant differences observed at 6 months. WeChat activity did not significantly influence anxiety or depression scores. The findings highlight a significant short-term dose‒response relationship, endorsing nurse-led CBT interventions for mental health in PLWH. Organizational strategies should focus on incentivizing and facilitating patient engagement, particularly through enhancing WeChat features.

The association between stigma and wellbeing in an Italian cohort of PLWH: The role of social support and personal factors

Our aim was to assess the association between different types of stigma and physical, behavioural and emotional wellbeing, and to evaluate whether these associations were mediated by the level of social support, age, education, sex and time from HIV diagnosis in an Italian cohort of people living with HIV (PLWH). We enrolled 96 PLWH and had them complete a cross-sectional online survey that included the "HSS-12", the "SF-12" and the "DASS-21". We performed linear regression analyses to explore the associations between the HSS-12 scores and cART adherence, viral load, SF-12 and DASS-21 scores, and a mediation analysis to identify mediators in the significant associations. We showed that higher level of depression and worse perception of mental health were significantly associated with higher HSS-12 "personalised stigma" (p = .009, p = .020) "disclosure concerns" (p = .012, p = .039), "concerns about public attitudes" (p =.007, p = .005) and "negative self-image" scores; (p < .001, p = .001); worse perception of physical health status was associated with higher HSS-12 "personalised stigma" scores (p = .018); higher level of anxiety and stress were associated with higher "negative self-image" scores (0.001 and p < .001). The association between higher HSS-12 "negative self-image" and higher levels of depression, anxiety and stress were mediated by lower age (a*b = +0.10; a*b = +0.12; a*b = +0.11). This study may have important implications for clinical practice as it contributes to understanding the characteristics and consequences of HIV-related stigma in a population of PLWH with excellent viroimmunological status and therapeutic adherence.

Bridging internalized HIV stigma and depressive symptoms among people living with HIV in China during the COVID-19 pandemic: a network analysis

Previous research has documented that HIV-related stigma may be a significant trigger of mental health problems among people living with HIV (PLWH). However, less is known about how internalized HIV stigma is linked to depressive symptoms among PLWH during the COVID-19 pandemic. The current study sought to explore the network structure of internalized HIV stigma and depressive symptoms, along with bridge nodes, to elucidate how they co-exist. Participants were 1,197 Chinese PLWH (64.3% male, Mage = 41.52, SD = 9.20) who completed the measurements of internalized HIV stigma and depressive symptoms during the early phase of the COVID-19 outbreak (May 2020). Results revealed that "ashamed of having HIV" was identified as the most central nodes in the internalized HIV stigma network, whereas "mind wandered during tasks" ranked highest on centrality in the depressive symptoms network. Two bridge connections were exhibited within the combined internalized HIV stigma and depressive symptoms network model: "inferiority due to HIV" and "gloomy feelings" from internalized HIV stigma and depressive symptoms communities, respectively. This study is one of the first to examine the co-occurrence of internalized HIV stigma and depressive symptoms in the context of the COVID-19 pandemic using a network approach. These findings have potential clinical implications for mitigating depressive symptoms in populations facing socioeconomic disadvantage and vulnerability.

Effect of the Friendship Bench Intervention on Antiretroviral Therapy Outcomes and Mental Health Symptoms in Rural Zimbabwe: A Cluster Randomized Trial

Importance

Common mental disorders (CMD), which include depression and anxiety, are prevalent among people living with HIV and are associated with suboptimal antiretroviral therapy (ART) adherence.

Objective

To assess the effect of a lay health worker-led psychological intervention on ART adherence, virologic suppression, and mental health symptoms.

Design, Setting, and Participants

Open-label pragmatic cluster trial with 1:1 block randomization of 16 health facilities in rural Bikita, Zimbabwe. Recruitment occurred from October 2018 to December 2019, and participants were followed up for 12 months, ending in December 2020. Participants were adults aged 18 years and older, who spoke English or Shona, screened positive for CMD (Shona Symptoms Questionnaire [SSQ]-14 score ≥9), received first-line ART for 6 or more months, had no World Health Organization stage 4 disease, no psychosis, were not pregnant, and provided informed consent. Data were analyzed from March 2021 to February 2022.

Intervention

The Friendship Bench, consisting of 6 lay health worker-led weekly problem-solving therapy sessions and optional peer-led group support.

Main Outcomes and Measures

The primary outcome was mean adherence during 2 to 6 months of follow-up, and the secondary outcomes were mean adherence during 1 to 12 months of follow-up, change in SSQ-14 and Patient Health Questionnaire (PHQ-9) scores (3, 6, 9, and 12 months), and viral load suppression (6 and 12 months).

Results

A total of 516 participants were recruited (244 in Friendship Bench and 272 in enhanced standard care facilities); 438 (84.9%) were female and the mean (SD) age was 45.6 (10.9) years. Mean (SD) adherence between 2 to 6 months was 89.9% (18.4%) in the Friendship Bench group and 87.2% (20.1%) in the control group. The intervention had no statistically significant effect on adherence between 2 to 6 months (unadjusted mean difference, 1.93 percentage points; 95% CI, -1.20 to 5.06 percentage points; P = .23), between months 1 to 12 (mean difference 0.79 percentage points; 95% CI, -2.14 to 3.71 percentage points; P = .60), or viral suppression. Declines in SSQ-14 scores from baseline to 3 months (difference, -1.65; 95% CI, -3.07 to -0.24), 6 months (difference, -1.57; 95% CI, -2.98 to -0.15), and 9 months (difference, -1.63; 95% CI, -3.05 to -0.22) were greater in the Friendship Bench than the standard care group (P < .05). There were no differences in the decline in the SSQ-14 scores from baseline to 12 months and in declines in PHQ-9 scores from baseline to 3, 6, 9, and 12 months.

Conclusions and Relevance

In this randomized trial of HIV-positive participants with CMD, the Friendship Bench intervention had no effect on adherence and viral suppression, possibly due to the absence of skill-based adherence training and a ceiling effect.

Trial Registration

ClinicalTrials.gov Identifier: NCT03704805.

Characteristics of mental health interventions in a cohort of Italian PLWH over the last five years: impact of HIV disease and outbreak of COVID-19 pandemic

Evidence accumulated during past years confirm that people living with HIV (PLWH) still have to deal with comorbidities and chronic complications that can increase physical and psychological issues and can affect daily functioning, quality of life and mental health. Moreover, during the COVID-19 pandemic PLWH proved to be a population at increased risk of psychological distress. We explored the ongoing issues and the characteristics of the mental health interventions for which a cohort of Italian PLWH interacted with a psychologist over the past five years. We analysed a dataset that included 61 PLWH who underwent a psychological intervention between 2018 and 2022. We compared different frequencies in characteristics of mental health interventions according to different demographic and clinical variables, psychopathological symptoms and time of the request for intervention. We showed that psychopathological symptoms most frequently reported by patients were anxiety (55.7%), and depression (49.2%). Furthermore, we reported that most our patients undertook occasional psychological support meetings (31%), sought an intervention after the outbreak of the COVID-19 pandemic (62.3%) and complained about disclosure issues (48.5%). Disclosure issues were mainly reported by younger PLWH (p = 0.002) with a shorter disease (p = 0.031) and treatment history (p = 0.032), and higher interpersonal sensitivity (p = 0.042). It seems fundamental to integrate psychological interventions into the care of PLWH, to give particular attention to PLWH with risky demographic, clinical and mental health factors and to pay special attention to emergency conditions (such as the COVID-19 pandemic) and the most widespread issues to create ad hoc interventions.

Comparative efficacy of psychological interventions on immune biomarkers: A systematic review and network meta-analysis (NMA)

Psychological interventions are viable, cost-effective strategies for improving clinical and psychological impact of inflammation-related conditions. However, their efficacy on immune system function remains controversial. We performed a systematic review and frequentist random-effects network meta-analysis of randomised controlled trials (RCTs) assessing the effects of psychological interventions, against a control condition, on biomarkers of innate and adaptive immunity in adults. PubMed, Scopus, PsycInfo, and Web of Science were searched from inception up to Oct 17, 2022. Cohen's d at 95% confidence interval (CI) was calculated to assess the effect sizes of each class of intervention against active control conditions at post-treatment. The study was registered in PROSPERO (CRD42022325508). Of the 5024 articles retrieved, we included 104 RCTs reporting on 7820 participants. Analyses were based on 13 types of clinical interventions. Compared with the control conditions, cognitive therapy (d =  - 0.95, 95% CI: -1.64 to - 0.27), lifestyle (d =  - 0.51, 95% CI: -0.99 to - 0.02), and mindfulness-based (d =  - 0.38, 95% CI: -0.66 to - 0.09) interventions were associated with post-treatment reduction of proinflammatory cytokines and markers. Mindfulness-based interventions were also significantly associated with post-treatment increase in anti-inflammatory cytokines (d = 0.69, 95% CI: 0.09 to 1.30), while cognitive therapy was associated also with post-treatment increase in white blood cell count (d = 1.89, 95% CI: 0.05 to 3.74). Results on natural killer cells activity were non-significant. Grade of evidence was moderate for mindfulness and low-to-moderate for cognitive therapy and lifestyle interventions; however, substantial overall heterogeneity was detected in most of the analyses.

Effect of autogenic training on quality of life and symptoms in people living with HIV: A mixed method randomized controlled trial

OBJECTIVE

Quality of life of people living with HIV is strongly affected by sleep problems, fatigue, pain, anxiety, and depression symptoms. This study set out to evaluate the effects of autogenic training (AT) on quality of life and symptoms within this population.

METHODS

A mixed method randomized controlled trial was conducted. Participants were randomly assigned to either the AT group (n = 32) or the control group (CG) (n = 31). Quality of life and symptoms were measured in both groups three times: prior to intervention (T0), immediately after intervention (T3), and three months after intervention (T6). Fourteen individual interviews were conducted.

RESULTS

Results show a significant improvement in social and mental dimensions of quality of life for the two groups at T6. They also show a significant improvement in sleep for AT participants at T3. Qualitative results are consistent with quantitative ones.

CONCLUSION

AT seems to improve sleep quality and could improve some dimensions of quality of life and other symptoms among people living with HIV. Further studies are needed to confirm these results.

TRIAL REGISTRATION NUMBER

NCT01901016.

Effect of the Friendship Bench intervention on antiretroviral therapy outcomes and mental health symptoms in rural Zimbabwe: A cluster randomized trial

Importance

Common mental disorders (CMD) are prevalent in people living with HIV and associated with suboptimal antiretroviral therapy (ART) adherence.

Objective

To assess the effect of a lay health worker-led psychological intervention on adherence to ART, virologic suppression and mental health symptoms.

Design

Pragmatic cluster trial with block randomization of health facilities. Treatment assignment was known to participants, providers, evaluators, and data analysts. Recruitment started in October 2018 and the last follow-up visit was done in December 2020. Participants were followed up for 12 months.

Setting

Sixteen public health care facilities in Bikita, a rural district in Masvingo Province, about 300 km south of Harare.

Participants

Men and non-pregnant women aged 18 years or older who spoke English or Shona, screened positive for CMD (Shona Symptoms Questionnaire [SSQ]-14 score ≥9), had received first-line ART for at least six months, had no WHO clinical stage 4 disease, no psychotic symptoms, and gave informed consent.

Intervention

The Friendship Bench, a lay health worker-led intervention consisting of six weekly individual counselling sessions of problem-solving therapy and optional peer-led group support.

Main Outcomes and Measures

The primary outcome was Medication Event Monitoring System (MEMS) mean adherence between 2-6 months of follow-up. Secondary outcomes included mean adherence between 1-12 months, change from baseline SSQ-14 and Patient Health Questionnaire (PHQ-9) score at 3, 6, 9, and 12 months and change in viral load suppression (viral load <1000 copies per mL) at months 6 and 12.

Results

We recruited 516 participants, 244 in Friendship bench and 272 in standard care facilities. The mean age was 45.6 years (SD 10.9), and most participants were women (84.9%). In the Friendship Bench group, 88.1% of participants attended all six individual counselling sessions. Rates of adherence (>85%) and virologic suppression (>90%) were high in both groups. The intervention had no statistically significant effect on adherence or viral suppression. Declines in SSQ-14 scores from baseline to 3 months (-1.65, 95% CI -3.07 to -0.24), 6 months (-1.57, 95% CI -2.98 to -0.15), and 9 months (-1.63, 95% CI -3.05 to -0.22) were greater in the Friendship Bench than the standard care group (p<0.05). There were no differences in the decline in the SSQ-14 scores from baseline to 12 months and in declines in PHQ-9 scores from baseline to 3, 6, 9, and 12 months.

Conclusions and Relevance

The Friendship Bench intervention is a feasible and acceptable approach to closing the treatment gap in mental health care in rural Zimbabwe. The intervention improved CMD symptoms but the intervention effect was smaller than previously shown in an urban setting. The intervention had no effect on adherence and viral suppression, possibly due to the absence of skill-based adherence training and ceiling effect.

Trial registration

ClinicalTrials.gov Identifier: NCT03704805.

Key points

Question: Does the Friendship Bench intervention improve antiretroviral therapy (ART) adherence, viral suppression and mental health symptoms in people living with HIV in rural Zimbabwe?Findings: In this cluster-randomized trial, participants in the intervention group had a significantly greater decrease in symptoms of common mental disorders than those in the control group, but the intervention showed no significant effect on antiretroviral therapy (ART) adherence or viral suppression.Meaning: The intervention did not affect adherence and viral suppression and the effect of the intervention on mental health symptoms was smaller than previously shown.

Unraveling the central and bridge psychological symptoms of people living with HIV: A network analysis

Background

People living with HIV (PLWH) experience multiple psychological symptoms. Few studies have provided information on central and bridge psychological symptoms among PLWH. This information has implications for improving the efficiency and efficacy of psychological interventions. Our study aimed to identify the central and bridge psychological symptoms of PLWH and to explore the interconnectedness among symptoms and clusters.

Methods

Our study used data from the HIV-related Symptoms Monitoring Survey, a multisite, cross-sectional study conducted during 2017-2021. We used R to visualize the network of 16 symptoms and analyzed the centrality and predictability indices of the network. We further analyzed the bridge symptoms among the three symptom clusters.

Results

A total of 3,985 participants were included in the analysis. The results suggested that sadness had the highest strength (r S = 9.69) and predictability (70.7%) compared to other symptoms. Based on the values of bridge strength, feeling unsafe (r bs = 0.94), uncontrollable worry (r bs = 0.82), and self-abasement (r bs = 0.81) were identified as bridge symptoms. We also found a strong correlation between sadness and self-abasement (r = 0.753) and self-loathing and self-blame (r = 0.744).

Conclusion

We found that sadness was the central psychological symptom of PLWH, indicating that sadness was the center of the psychological symptom network from a mechanistic perspective and could be a target for intervention. Deactivating bridge symptoms, including "feeling unsafe," "self-abasement," and "uncontrollable worry," could be more effective in preventing symptom activation from spreading (e.g., one symptom activating another).

Cognitive Behavioral Therapy for AIDS Prevention among College Students in China: A Cluster Randomized Controlled Trial

BACKGROUND

Acquired immune deficiency syndrome (AIDS) is a serious worldwide public health problem and has become the focus of prevention and control in China, while the student population is the key population for AIDS prevention.

OBJECTIVE

The purpose of this study was to investigate the effects of cognitive behavioral therapy (CBT) on college students' AIDS-related cognitions, attitudes, and behaviors, and to find programmatic strategies for AIDS prevention in terms of changing college students' cognitions and behaviors.

METHODS

In a cluster randomized controlled trial, 233 undergraduate students were assigned to the CBT group (CBT-based intervention, n=92), the TAU group (treatment as usual, n=72), and the CON group (no intervention, n=59). AIDS-related knowledge, attitudes, and behaviors of participants were assessed at pre-intervention, post-intervention, and follow-up.

RESULTS

After one month of the study, AIDS-related knowledge, attitudes, and behaviors improved in both the TAU and CBT groups, while there were no significant changes in the CON group. The intervention effect was more significant and sustainable in the CBT group compared to the TAU group.

CONCLUSIONS

The application of CBT in AIDS prevention among college students is feasible, acceptable, and effective. CBT can increase the level of knowledge about AIDS, improve AIDS-related attitudes, and increase willingness to use condoms. CBT is expected to replace traditional health education as an innovative tool for AIDS prevention because of its long-lasting and efficacious nature.

The benefits of psychosocial interventions for mental health in men who have sex with men living with HIV: a systematic review and meta-analysis

OBJECTIVE

Men who have sex with men (MSM) living with HIV are more likely to suffer from mental health problems. They should be given adequate attention to treat and improve their mental health disorders. This meta-analysis aimed to assess whether psychosocial interventions reliably improve psychological well-being among MSM living with HIV.

METHOD

Cochrane Library, EMBASE, PsycINFO, and PubMed were searched for psychosocial intervention randomized controlled trials evaluating mental health (e.g., depression, anxiety, self-efficacy). The effect size was pooled using the random-effects model, and continuous outcomes were reported using standardized mean difference (SMD) values .

RESULTS

A total of 12 studies including 1782 participants were included in the meta-analysis. Psychosocial interventions in contrast to control groups significantly reduced depression (SMD, - 0.28; 95% CI - 0.52 - - 0.03) at the follow-up assessment and improved quality of life (SMD 0.43, 95% CI 0.23-0.63) after treatment. Psychosocial interventions also had a significant effect on measures of self-efficacy (SMD 2.22, 95% CI 0.24-4.20), and this effect was sustained until long-term follow-up (SMD 0.55, 95% CI 0.02-1.08). Subgroup analyses revealed that improvements in depression were more significant when participants possessed higher education and treatment providers used cognitive behavioral therapy (CBT).

CONCLUSIONS

The findings of this study indicate that psychosocial interventions benefit the mental health of MSM living with HIV. It is necessary to conduct more research to explore characteristics that may affect treatment outcomes in the future.

TRIAL REGISTRATION

This research was prospectively registered in PROSPERO ( CRD42021262567 ).

Effects of cognitive behavioral therapy on improving depressive symptoms and increasing adherence to antiretroviral medication in people with HIV

The incidence of depression is higher in PLWH (people living with HIV) than in the general population. It is of clinical significance to explore effective measures to improve depression in patients. But the available evidence is still quite limited. CBT (cognitive behavioral therapy) is considered to be one of the effective methods to improve depression, medication adherence and quality of life in PLWH. Therefore, this study aimed to systematically evaluate the effect of cognitive behavioral therapy on improving depressive symptoms and increasing adherence to antiretroviral therapy (ART) in people living with HIV (Human Immunodeficiency Virus). The Cochrane Library, Embase, PubMed, and Web of Science databases were searched by computer to collect randomized controlled trials on the effects of cognitive behavioral therapy on improving depression and increasing ART medication adherence in PLWH, and the retrieval time was from the inception of each database to January 10, 2022. Meta-analysis was performed by two researchers using Stata 15.0 software after screening the literature, extracting data and evaluating quality according to inclusion and exclusion criteria. A total of 16 studies with 1,998 patients were included. Meta-analysis results showed that CBT improved depressive symptoms in PLWH (SMD = -0.09, 95% CI [-0.13 to -0.04], P < 0.001) with better long-term (<6 months) depression improvement (SMD = -0.09, 95% CI [-0.15 to -0.02], P = 0.006) than short-term (0-6 months); the difference in improved ART medication adherence in the CBT group compared to the control group was not statistically significant (SMD = 0.04, 95% CI [-0.06 to 0.13], P = 0.490). There may be publication bias due to incomplete inclusion of literature as only published literature was searched. Cognitive behavioral therapy is effective in improving depressive symptoms in people living with HIV, with better long-term (>6 months) results than short-term (0-6 months).

Understanding Medical Distrust Among African American/Black and Latino Persons Living With HIV With Sub-Optimal Engagement Along the HIV Care Continuum: A Machine Learning Approach

Medical distrust is a potent barrier to participation in HIV care and medication use among African American/Black and Latino (AABL) persons living with HIV (PLWH). However, little is known about sociodemographic and risk factors associated with distrust. We recruited adult AABL PLWH from low socio-economic status backgrounds with insufficient engagement in HIV care (N = 512). Participants completed structured assessments on three types of distrust (of health care providers, health care systems, and counter-narratives), HIV history, and mental health. We used a type of machine learning called random forest to explore predictors of trust. On average, participants were 47 years old (SD = 11 years), diagnosed with HIV 18 years prior (SD = 9 years), and mainly male (64%) and African American/Black (69%). Depression and age were the most important predictors of trust. Among those with elevated depressive symptoms, younger participants had less trust than older, while among those without depression, trust was greater across all ages. The present study adds nuance to the literature on medical distrust among AABL PLWH and identifies junctures where interventions to build trust are needed most.

HIV and antiretroviral treatment knowledge gaps and psychosocial burden among persons living with HIV in Lima, Peru

This study aims to describe knowledge on HIV and antiretroviral (ARV) treatment and psychosocial factors among people living with HIV (PLWH) in Lima, Perú, to explore characteristics associated to this knowledge, and determine its impact on sustained viral suppression. A cross-sectional survey was conducted among 171 PLWH at the largest referral health care center in Lima. The psychosocial factors measured were depression, risk of alcoholism, use of illegal drugs and disclosure. A participant had "poor knowledge" when less than 80% of replies were correct. Sustained viral suppression was defined as two consecutive viral loads under 50 copies/mL. A total of 49% and 43% had poor HIV and ARV knowledge respectively; 48% of the study population screened positive for depression and 27% reported feeling unsupported by the person they disclosed to. The largest gaps in HIV and ARV knowledge were among 98 (57%) that did not recognize that HIV increased the risk of cancer and among 57 (33%) participants that did not disagree with the statement that taking a double dose of ARV if they missed one. Moderate depression was significantly associated to poor HIV and ARV knowledge. Non-disclosure and being on ARVs for less than 6 months were associated with not achieving sustained viral suppression. Our findings highlight important HIV and ARV knowledge gaps of PLWH and a high burden of psychosocial problems, especially of depression, among PLWH in Lima, Peru. Increasing knowledge and addressing depression and disclosure could improve care of PLWH.

Symptoms of common mental disorders and adherence to antiretroviral therapy among adults living with HIV in rural Zimbabwe: a cross-sectional study

OBJECTIVES

To examine the proportion of people living with HIV who screen positive for common mental disorders (CMD) and the associations between CMD and self-reported adherence to antiretroviral therapy (ART).

SETTING

Sixteen government-funded health facilities in the rural Bikita district of Zimbabwe.

DESIGN

Cross-sectional study.

PARTICIPANTS

HIV-positive non-pregnant adults, aged 18 years or older, who lived in Bikita district and had received ART for at least 6 months.

OUTCOME MEASURES

The primary outcome was the proportion of participants screening positive for CMD defined as a Shona Symptoms Questionnaire score of 9 or greater. Secondary outcomes were the proportion of participants reporting suicidal ideation, perceptual symptoms and suboptimal ART adherence and adjusted prevalence ratios (aPR) for factors associated with CMD, suicidal ideation, perceptual symptoms and suboptimal ART adherence.

RESULTS

Out of 3480 adults, 18.8% (95% CI 14.8% to 23.7%) screened positive for CMD, 2.7% (95% CI 1.5% to 4.7%) reported suicidal ideations, and 1.5% (95% CI 0.9% to 2.6%) reported perceptual symptoms. Positive CMD screens were more common in women (aPR 1.67, 95% CI 1.19 to 2.35) than in men and were more common in adults aged 40-49 years (aPR 1.47, 95% CI 1.16 to 1.85) or aged 50-59 years (aPR 1.51, 95% CI 1.05 to 2.17) than in those 60 years or older. Positive CMD screen was associated with suboptimal adherence (aPR 1.53; 95% CI 1.37 to 1.70).

CONCLUSIONS

A substantial proportion of people living with HIV in rural Zimbabwe are affected by CMD. There is a need to integrate mental health services and HIV programmes in rural Zimbabwe.

TRIAL REGISTRATION NUMBER

NCT03704805.

Mental health interventions for persons living with HIV in low- and middle-income countries: a systematic review

INTRODUCTION

Addressing the intersection between mental health and HIV is critical for the wellbeing of persons living with HIV (PLWH). This systematic review synthesized the literature on mental health interventions for PLWH in low- and middle-income countries (LMICs) to determine intervention components and explore their relationship with intervention effectiveness.

METHODS

We included only controlled clinical trials of interventions aiming to improve the mental health of PLWH. We conducted a search in the following databases: PubMed, CINAHL, PsycINFO and EMBASE for eligible studies describing the evaluation of interventions for mental health problems among PLWH in LMICs published through August 2020. Two reviewers independently screened references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria.

RESULTS

We identified a total of 30 eligible articles representing 6477 PLWH who were assigned to either the intervention arm (n = 3182) or control arm (n = 3346). The mental health interventions evaluated were psychological (n = 17, 56.67%), pharmacological (n = 6, 20.00%), combined psychological and pharmacological (n = 1, 3.33%) and complementary/alternative treatments (n = 6, 20.00%). The mental health problems targeted were depression (n = 22, 73.33 %), multiple psychological symptoms (n = 1, 3.33%), alcohol and substance use problems (n = 4, 13.33%), post-traumatic stress disorder (n = 1, 3.33%) and HIV-related neuro-cognitive impairment (n = 2, 6.67%). Studies of interventions with significant effects had significantly a higher number of active ingredients than those without significant effects [3.41 (2.24) vs. 1.84 (1.46) Mean (SD)] [Mean difference = -1.56, 95% CI = -3.03 to -0.09, p = 0.037].

CONCLUSIONS

There continue to be advances in mental health interventions for PLWH with mental illness in LMICs. However, more research is needed to elucidate how intervention components lead to intervention effectiveness. We recommend scale up of culturally appropriate interventions that have been successfully evaluated in low- and middle-income countries.

A Systematic Review and Meta-analysis of Telephone-Based Therapy Targeting Depressive Symptoms Among Low-Income People Living with HIV

People living with human immunodeficiency virus (PLWH) has been reported to have a high prevalence of depressive symptoms. Low-income populations account for a large proportion of PLWH, hence indicating a high level of depressive symptoms in low-income PLWH. Telephone-based therapy has been shown to be effective for treating PLWH's depressive symptoms, but its effects among low-income PLWH remain unclear. The purpose of this meta-analysis was to evaluate the effects of telephone-based therapy targeting depressive symptoms among low-income PLWH. Six databases (PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure, VIP Database and Wanfang Data) were searched until May 2020 using search terms related to telephone-based therapy, depressive symptoms, and PLWH. Eight studies were included in the meta-analysis. Both postintervention effects (primary outcome) and long-term effects (secondary outcome) were evaluated using a random effects model. The meta-analysis revealed a small to moderate effect size (ĝ = - 0.29, 95% CI - 0.51, - 0.06) on reducing depressive symptom scores (Z = 2.51, p = 0.01) in telephone-based intervention group compared with the control group at postintervention. However, there was no statistically significant long-term effects (Z = 0.77, p = 0.44) at follow-up. For postintervention effects, calculation of the I² index indicated moderate heterogeneity (I² = 50%); sensitivity analysis and subgroup analysis were performed to explore the source of heterogeneity. Ethnic group was classified into minority and majority which refers to most of the population were ethnic minority and majority respectively. Between-group differences were found across ethnic groups. The results suggested that there was a slightly stronger effect of telephone-based therapy in low-income PLWH than among PLWH in general, but its long-term effect requires future investigation. The effects of the intervention were better among the ethnic majority subgroups of low-income PLWH. Treatment format and intervention duration might also influence the intervention effects. However, the overall quality of evidence was low and directly impacted on the interpretation of our results, suggesting that more high-quality random controlled trial (RCT)/longitudinal studies with less selection and detection bias, less inconsistency and less indirectness are needed when applying telephone-based therapy to low-income PLWH with depressive symptoms in further studies.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Immunological and Psychological Efficacy of Meditation/Yoga Intervention Among People Living With HIV (PLWH): A Systematic Review and Meta-analyses of 19 Randomized Controlled Trials

BACKGROUND

An expanding number of mind-body therapies are being used to reduce the psychological burden of peoples living with human immunodeficiency virus (HIV). However, the effects on the immune system and mental health varied among studies.

PURPOSE

This meta-analysis was conducted to summarize the randomized controlled trials to draw comprehensive conclusions regarding the psycho-immunological efficacy.

METHODS

Random-effects models were used to assess the outcome of interest. Egger's tests were used to identify publication bias. Subgroup and meta-regression were used to explore potential moderators. This review was registered on the PROSPERO database (CRD42019148118).

RESULTS

Nineteen randomized controlled trials with a total sample size of 1,300 were included in this meta-analysis. Regarding immune system outcome, mind-body therapy significantly improved CD4 T-cell counts (Cohen's d = 0.214, p = .027) and maintained (0.427, p = .049). In addition, baseline CD4 T-cell counts and years since HIV diagnosis significantly moderated the efficacy of mind-body practices on CD4 improvement (all ps < .001). Regarding mental health outcome, mind-body therapy significantly reduced stress, depression, and anxiety symptoms (0.422, p < .001; 0.506, p < .001, and 0.709, p < .001, respectively) while improving quality of life (0.67, p < .001).

CONCLUSIONS

Meditation/yoga intervention could result in potential benefits with regard to improved CD4 T-cell counts immediately after the intervention and at long-term follow-up, while also improving their mental health. The cost-effective meditation/yoga intervention should be integrated into routine care for people living with HIV, especially for those with lower CD4 baseline and fewer years since diagnosis.

Contribution of Behavioral Health Factors to Non-AIDS-Related Comorbidities: an Updated Review

PURPOSE OF REVIEW

We summarize recent literature on the contribution of substance use and depression to non-AIDS-related comorbidities. Discussion of recent randomized clinical trials and implementation research to curtail risk attributed to each behavioral health issue is provided.

RECENT FINDINGS

Smoking, unhealthy alcohol use, opioid use, and depression are common among PWH and individually contribute to increased risk for non-AIDS-related comorbidities. The concurrence of these conditions is notable, yet understudied, and provides opportunity for linked-screening and potential treatment of more than one behavioral health factor. Current results from randomized clinical trials are inconsistent. Investigating interventions to reduce the impact of these behavioral health conditions with a focus on implementation into clinical care is important. Non-AIDS-defining cancers, cardiovascular disease, liver disease, and diabetes are leading causes of morbidity in people with HIV. Behavioral health factors including substance use and mental health issues, often co-occurring, likely contribute to the excess risk of non-AIDS-related comorbidities.

Systematic review and meta-analyses of randomized control trials of the effectiveness of psychosocial interventions for homeless adults

AIMS

To evaluate the effect of psychosocial interventions for homeless adults on their psychosocial outcomes.

DESIGN

A systematic review and meta-analyses were performed for critical appraisal and synthesis of the included studies.

DATA SOURCES

A systematic search of studies published before 10 September 2018 was performed using PubMed, Cochrane Library, EMBASE, PsycINFO, and CINAHL.

REVIEW METHODS

The review included randomized controlled trials conducting psychosocial interventions and assessing psychosocial outcomes for homeless adults. After systematically describing study and intervention characteristics, we conducted meta-analyses by the type of outcome and subgroup meta-analyses by the type of intervention and outcome. Fourteen studies were included in this review and 11 were included in the meta-analyses.

RESULTS

A significant effect of psychosocial interventions in reducing anxiety and enhancing mental health status among homeless adults was noted.

CONCLUSION

The meta-analyses showed that psychosocial interventions may reduce anxiety and enhance the mental health status of homeless people. Specifically, we suggest that relaxation response training may be effective in improving anxiety and mental health status and cognitive behavioural therapy may reduce anxiety.

IMPACT

Although psychosocial interventions for homeless persons have been implemented for a decade, their impact for psychosocial outcomes among homeless adults has not been evaluated. This review suggest that psychosocial interventions may improve anxiety and mental health status among homeless adults. The findings of the present study may provide directions for developing psychosocial interventions to help vulnerable homeless adults in managing psychological outcomes.