Development and implementation of a peer-based mental health support programme for adolescents orphaned by HIV/AIDS in South Africa

Mental health and psychosocial interventions integrating sexual and reproductive rights and health, and HIV care and prevention for adolescents and young people (10-24 years) in sub-Saharan Africa: a systematic scoping review

Background

Interventions targeting combined sexual and reproductive health, Human Immunodeficiency Virus (HIV) management and mental health care in sub-Saharan Africa (SSA) are few. There is a need to address common determinants of poor mental, psychosocial and sexual and reproductive health and rights (SRHR) through multimodal and multipronged interventions for adolescents. The main objective of this study was to identify whether and how interventions targeting adolescent SRHR and HIV with a focus on pregnant and parenting adolescents in SSA include mental health components and how these components and their outcomes have been reported in the literature.

Methods

We carried out a two process scoping review approach between 01.04.2021 and 23.08.2022. In the first stage, we searched the PubMed database to identify studies focusing on adolescents and young people aged 10 to 24 from 2001 to 2021. We identified studies focusing on HIV and SRHR that had mental health and psychosocial aspects to the interventions. Our search yielded 7025 studies. Of these 38 were eligible based on our screening criteria that covered interventions, and on further scrutiny, using PracticeWise, an established coding system, we identified select problems and practices to provide a more granular assessment of how interventions developed for this context mapped on to specific problems. At this second stage process, we selected 27 studies for inclusion as actual interventional designs for further systematic scoping of their findings and we used the Joanna Briggs Quality Appraisal checklist to rate these studies. This review was registered within the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42021234627.

Findings

Our first set of findings is that when coding problems and solutions, mental health concerns were the least common category of problems targeted in these SRHR/HIV interventions; nevertheless, psychoeducation and cognitive behavioral strategies such as improved communication, assertiveness training, and informational support were offered widely. Of the 27 interventional studies included in the final review, 17 RCTs, 7 open trials, and 3 mixed designs, represented nine countries of the 46 countries in SSA. Intervention types included peer, community, family, digital, and mixed modality interventions. Eight interventions focused on caregivers and youth. Social or community ecology associated problems (being an orphan, sexual abuse, homelessness, negative cultural norms) were the most common risk factors and were more frequent than medical issues associated with HIV exposure. Our findings highlight the relevance and centrality of social issues related to adolescent mental and physical health along with the need to strengthen multimodal interventions along the lines of problems we have identified in our review.

Interpretation

Combined interventions jointly addressing adolescent SRHR, HIV, and mental health have been relatively understudied, despite evidence that adverse social and community factors are rampant in this population.

Funding

MK was funded by Fogarty International CenterK43 TW010716-05 and lead the initiative.

"Those People Motivate and Inspire Me to Take My Treatment." Peer Support for Adolescents Living With HIV in Cape Town, South Africa

Adherence to antiretroviral therapy (ART) and psychosocial support to manage stigma and disclosure is essential for adolescents living with HIV (ALHIV). Peer support groups can help ALHIV and their families live successfully with HIV. This qualitative study aimed to examine adolescent and caregiver perspectives on peer support groups. Three themes emerged: (1) peer support encouraged adherence to ART, (2) serostatus disclosure outside the family was perceived as difficult, and (3) the peer support group fostered fundamental and meaningful peer relationships for ALHIV. Caregivers felt peer support groups increased self-acceptance and adherence for ALHIV across 3 domains: (1) as motivation for families and adolescents, (2) to increase adolescent independence and maturity, and (3) to help adolescents accept their HIV status and live successfully with HIV. These data highlight the importance of psychosocial support groups for ALHIV and caregivers, illustrating the benefits of a safe space with trusted relationships and open communication.

Mental health, substance use and viral suppression in adolescents receiving ART at a paediatric HIV clinic in South Africa

INTRODUCTION

Mental health problems are prevalent in adolescents living with HIV (ALHIV), often remain untreated, and may negatively affect antiretroviral therapy (ART) adherence and viral suppression. We implemented routine mental health screening at a paediatric ART clinic to improve the identification and management of mental health problems in ALHIV. In this report, we examine screening outcomes, associated patient characteristics and the odds of unsuppressed viral load in ALHIV screening positive for mental disorders.

METHODS

Adolescents aged 10 to 19 years attending Rahima Moosa Hospital in Johannesburg, South Africa between February 1, 2018, and January 1, 2020, were offered mental health screening at each routine HIV care visit. The screening included four pre-screening questions followed by full screening (conditional on positive pre-screening) for depression (Patient Health Questionnaire-9 [PHQ-9]), suicide (Adolescent Innovations Project [AIP]-handbook), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), post-traumatic stress disorder (PTSD) (Primary Care PTSD Screen [PC-PTSD-5]) and substance use (CAGE Adapted to Include Drugs [CAGE-AID]). We assessed screening outcomes and calculated adjusted odds ratios for associations between positive screening tests at the first screen and unsuppressed viral load (>400 copies/mL) at the measurement taken closest to the date of screening, within hundred days before and one day after screening.

RESULTS

Out of 1203 adolescents who attended the clinic, 1088 (90.4%) were pre-screened of whom 381 (35.0%) underwent full screening, 48 (4.4%) screened positive for depression (PHQ-9 ≥10), 29 (2.8%) for suicidal concern, 24 (2.2%) for anxiety (GAD-7 ≥10), 38 (3.2%) for PTSD (PC-PTSD-5 ≥3), 18 (1.7%) for substance use (CAGE-AID ≥2) and 97 (8.9%) for any of these conditions. Positive screening for depression (aOR 2.39, 95% CI 1.02 to 5.62), PTSD (aOR 3.18, 95% CI 1.11 to 9.07), substance use (aOR 7.13, 95% CI 1.60 to 31.86), or any condition (aOR 2.17, 95% CI 1.17 to 4.02) were strongly associated with unsuppressed viral load.

CONCLUSIONS

ALHIV affected by mental health problems have increased rates of unsuppressed viral load and need specific clinical attention. The integration of routine mental health screening in paediatric ART programmes is a feasible approach for identifying and referring adolescents with mental health and adherence problems to counselling and psychosocial support services and if needed to psychiatric care.

Measuring change in vulnerable adolescents: findings from a peer education evaluation in South Africa

INTRODUCTION

In the context of poverty and HIV and AIDS, peer education is thought to be capable of providing vulnerable youth with psychosocial support as well as information and decision-making skills otherwise limited by scarce social and material resources. As a preventative education intervention method, peer education is a strategy aimed at norms and peer group influences that affect health behaviours and attitudes. However, too few evaluations of peer-led programmes are available, and they frequently fail to reflect real differences between those who have been recipients of peer education and those who have not. This article reports on an evaluation of a pilot peer-led intervention, entitled Vhutshilo, implemented on principles agreed upon through a collaborative effort in South Africa by the Harvard School of Public Health and the Centre for the Support of Peer Education (the Rutanang collaboration). Vhutshilo targeted vulnerable adolescents aged 14-16 years living in some of South Africa's under-resourced communities.

METHODOLOGY

The research design was a mixed-method (qualitative and quantitative), longitudinal, quasi-experimental evaluation. Tools used included a quantitative survey questionnaire (n = 183) and semi-structured interviews (n = 32) with beneficiaries of peer education. Surveys were administered twice for beneficiaries of peer education (n = 73), immediately after completion of the programme (post-test) and 4 months later (delayed post-test), and once for control group members (n = 110). The three main methodological limitations in this study were the use of a once-off control group assessment as the baseline for comparison, without a pre-test, due to timing and resource constraints; a small sample size (n = 183), which reduced the statistical power of the evaluation; and the unavailability of existing tested survey questions to measure the impact of peer education and its role in behaviour change.

FINDINGS

This article reports on the difficulties of designing a comprehensive evaluation within time and financial constraints, critically evaluates survey design with multi-item indicators, and discusses six statistically significant changes observed in Vhutshilo participants out of a 92-point survey. Youth struggling with poor quality education and living in economically fraught contexts with little social support, nonetheless, showed evidence of having greater knowledge of support networks and an expanded emotional repertoire by the end of the Vhutshilo programme, and 4 months later. At both individual and group level, many with low socio-economic status showed great improvement with regard to programme indicator scores.

CONCLUSION

For the poorest adolescents, especially those living in the rural parts of South Africa, peer education has the potential to change future orientation, attitudes and knowledge regarding HIV and AIDS, including an intolerance for multiple concurrent partnerships. When well organised and properly supported, peer education programmes (and the Vhutshilo curriculum, in particular) provide vulnerable youth with opportunities to develop psychosocial skills and informational resources that contribute to the changing of norms, attitudes and behaviours. However, the article also flags the need for effective peer education evaluations that take into account limited financial resources and that possess tested indicators of programme effectiveness.