Rural Friendship Bench: A qualitative study in Zaka district, Zimbabwe

BACKGROUND

We piloted the Friendship Bench-an evidence-based, urban-area task sharing intervention for common mental disorders-in rural Zimbabwe. The intervention combines problem solving therapy with income generating activities. This study sought to understand the intervention's implementation in terms of acceptability, feasibility, and sustainability as well as local attitudes towards mental wellbeing in rural Zimbabwe.

METHODS

Using four separate semi-structured interview guides, we conducted in-depth interviews (N = 32) with patients (n = 9), village health workers (n = 12), nurses (n = 6), and community leaders (n = 5). We analyzed our data using thematic analysis with a diverse coding team using an integrative deductive-inductive approach.

RESULTS

Five themes emerged: 1) explanatory models for mental illness, 2) clinical workflow and emphasis on documentation, 3) positive feedback about the Friendship Bench, 4) accessibility, and 5) feasibility.

CONCLUSION

In its current format, our intervention was acceptable but neither feasible nor sustainable. Sociocultural context is critical in the development of rural task sharing interventions for mental health. We thus recommend a robust pilot and adaptation phase when scaling task sharing interventions in rural sub-Saharan Africa to elevate community voices, leverage existing social structures, and embed interventions as deeply into communities as possible.

Effect of a brief psychological intervention for common mental disorders on HIV viral suppression: A non-randomised controlled study of the Friendship Bench in Zimbabwe

BACKGROUND

For people living with co-morbid HIV and common mental disorders (CMD), it is not known whether a brief psychological intervention for CMD can improve HIV viral suppression.

METHODS

We conducted a prospective cohort study in eight primary care clinics in Harare, Zimbabwe, enrolling adults with co-morbid HIV and CMD. Six clinics provided the Friendship Bench (FB), a brief psychological intervention for CMD based on problem-solving therapy, delivered by lay counsellors. Two clinics provided enhanced usual care (EUC). The primary outcome was viral non-suppression after six months (viral load ≥400 copies/mL). Data were analysed using a difference-in-difference approach with linear regression of cluster-level proportions, adjusted for baseline viral non-suppression (aDiD). The secondary outcome was presence of CMD measured by the Shona Symptom Questionnaire.

RESULTS

In FB clinics, 407/500 (81.4%) participants had viral load results at baseline and endline: 58 (14.3%) had viral non-suppression at baseline and 41 (10.1%) at endline. In EUC clinics, 172/200 (86.0%) had viral load results at baseline and endline: 22 (12.8%) were non-suppressed at baseline and 26 (15.1%) at endline (aDiD = -7.3%; 95%CI 14.7% to -0.01%; p = 0.05). Of the 499 participants virally suppressed at baseline, the FB group had lower prevalence of non-suppression at endline compared to the EUC group (2.9% vs 9.3%; p = 0.002). There was no evidence of a difference in endline viral non-suppression by group among the 80 participants with non-suppression at baseline (53.5% vs 54.6%; p = 0.93). The FB group was less likely to screen positive for CMD at endline than the EUC group (aDiD = -21.6%; 95%CI -36.5% to -6.7%; p = 0.008).

CONCLUSION

People living with co-morbid HIV and CMD may benefit from receiving a low-cost mental health intervention to enhance viral suppression, especially if they are already virally suppressed. Research is needed to understand if additional adherence counselling could further improve viral suppression.

Effectiveness of single-session therapy for adult common mental disorders: a systematic review

BACKGROUND

Common mental disorders (CMDs) impose significant socioeconomic impacts on the global community. Nevertheless, over 50% of individuals with CMDs do not receive proper treatment, indicating that the current treatment modalities do not adequately tackle this issue. Since single-session therapy (SST) is a potential method for reducing the treatment gap, it is crucial to evaluate its effectiveness. Therefore, this systematic review aimed to evaluate the effectiveness of SST on CMD symptoms in adults.

METHODS

This systematic review included randomised and non-randomised studies assessing the clinical effectiveness of SST on CMD symptoms in adults. English-written, peer-reviewed studies or dissertations were included, while grey literature was excluded. MEDLINE, Embase, PsycINFO, and Cochrane's CENTRAL were searched on December 13, 2022, from their inception dates. The risk of bias in the included studies was evaluated using RoB 2 and ROBINS-I. A narrative synthesis was performed. This systematic review was registered in the PROSPERO database on July 6, 2022 (CRD42022343925).

RESULTS

Six randomised and three non-randomised studies were included after screening 2,130 records. Three non-randomised studies with a "critical" or "serious" risk of bias were excluded from the synthesis. Therefore, six randomised trials involving 298 participants were included in the synthesis. Four out of six studies had a "high" risk of bias. The participants had non-severe symptoms at baseline, and three intervention types (behavioural activation, DBT, and solution-focused psychotherapy) were evaluated. Five of six studies showed positive results for depression, with only one reporting a positive result for anxiety.

CONCLUSIONS

SST may be effective in improving CMD symptoms in adults, particularly depression. However, there is a limit to deriving definite conclusions due to a high risk of bias in included studies, insufficient sample size and research volume. Further research exploring the characteristics of clients who can benefit from SST is required to facilitate its widespread use.

Global health reciprocal innovation to address mental health and well-being: strategies used and lessons learnt

Over the past two decades there have been major advances in the development of interventions promoting mental health and well-being in low- and middle-income countries (LMIC), including delivery of care by non-specialist providers, incorporation of mobile technologies and development of multilevel community-based interventions. Growing inequities in mental health have led to calls to adopt similar strategies in high-income countries (HIC), learning from LMIC. To overcome shared challenges, it is crucial for projects implementing these strategies in different global settings to learn from one another. Our objective was to examine cases in which mental health and well-being interventions originating in or conceived for LMIC were implemented in the USA. The cases included delivery of psychological interventions by non-specialists, HIV-related stigma reduction programmes, substance use mitigation strategies and interventions to promote parenting skills and family functioning. We summarise commonly used strategies, barriers, benefits and lessons learnt for the transfer of these innovative practices among LMIC and HIC. Common strategies included intervention delivery by non-specialists and use of digital modalities to facilitate training and increase reach. Common barriers included lack of reimbursement mechanisms for care delivered by non-specialists and resistance from professional societies. Despite US investigators' involvement in most of the original research in LMIC, only a few cases directly involved LMIC researchers in US implementation. In order to achieve greater equity in global mental health and well-being, more efforts and targeted funding are needed to develop best practices for global health reciprocal innovation and iterative learning in HIC and LMIC.

An Intervention to Improve Mental Health and HIV Care Engagement Among Perinatal Women in Malawi: A Pilot Randomized Controlled Trial

Perinatal depression (PND) is common and an important barrier to engagement in HIV care for women living with HIV (WLHIV). Accordingly, we adapted and enhanced The Friendship Bench, an evidence-based counseling intervention, for perinatal WLHIV. In a pilot randomized trial (NCT04143009), we evaluated the feasibility, acceptability, fidelity, and preliminary efficacy of the Enhanced Friendship Bench (EFB) intervention to improve PND and engagement in HIV care outcomes. Eighty pregnant WLHIV who screened positive for PND symptoms on the Self-Report Questionnaire (≥ 8) were enrolled, randomized 1:1 to EFB or usual care, and followed through 6 months postpartum. Overall, 100% of intervention participants were satisfied with the intervention and 93% found it beneficial to their overall health. Of 82 counseling sessions assessed for fidelity, 83% met or exceeded the fidelity threshold. At 6 months postpartum, intervention participants had improved depression remission (59% versus 36%, RD 23%, 95% CI 2%, 45%), retention in HIV care (82% versus 69%, RD 13%, -6%, 32%), and viral suppression (96% versus 90%, RD 7%, -7%, 20%) compared to usual care. Adverse events did not differ by arm. These results suggest that EFB intervention should be evaluated in a fully powered randomized trial to evaluate its efficacy to improve PND and engagement in HIV care outcomes for WLHIV.

Evaluation of the health-related quality of life and associated factors in Zimbabwean adults living with HIV: a cross-sectional study

OBJECTIVE

HIV remains a global burden, with the Sub-Saharan Africa (SSA) region reporting the largest number of people living with HIV/AIDS (PLHIV). An exponential improvement in the accessibility and uptake of antiretroviral treatment across SSA has significantly improved outcomes for PLHIV. Hence, HIV care goals have shifted from reducing mortality and morbidity to improving health-related quality of life (HRQoL). This study uses generic and condition-specific HRQoL outcomes to holistically determine the HRQoL of Zimbabwean adult PLHIV and associated factors. HRQoL is a dynamic subject construct that warrants continuous evaluation to provide meaningful feedback to various stakeholders. We enrolled 536 adult PLHIV in Zimbabwe. Collected data were analyzed through descriptive statistics and multivariate binary logistic regression.

RESULTS

Our study shows a high HRQoL perception by Zimbabwean PLHIV. Anxiety, depression, and poor environmental health were widely reported domains influencing HRQoL. Also, being aware of HIV status for over a year, not experiencing an adverse event, being married, having adequate finances and food security and having higher educational status were associated with higher HRQoL. It is essential to integrate mental health care into routine HIV care to improve treatment outcomes and HRQoL. Last, implementing bespoke multisectoral HRQoL-enhancement interventions is paramount.

Erratum: A community health volunteer delivered problem-solving therapy mobile application based on the Friendship Bench 'Inuka Coaching' in Kenya: A pilot cohort study - CORRIGENDUM

[This corrects the article DOI: 10.1017/gmh.2021.3.].

Reliability and validity of the Shona version of the Exercise Benefits and Barriers Scale in Zimbabwean adult people living with HIV/AIDS

Introduction

Despite the widely known benefits of physical activity (PA), only 25% of people living with HIV (PLHIV) meet the WHO-recommended minimum PA levels. Consequently, it is essential to understand PA barriers and facilitators using objective measures. Although the Exercise Benefits and Barriers Scale (EBBS) is extensively used, its psychometric evidence is fragmented and has not been previously validated in PLHIV. This study aimed to translate and validate the EBBS Shona version in Zimbabwean PLHIV.

Methods

A cross-sectional study was used to recruit 567 PLHIV from four (4/9) randomly selected polyclinics (primary healthcare facilities) in urban Harare, Zimbabwe. We recruited adult patients (aged ≥18 years) with a confirmed diagnosis of HIV. Participants had to be willing to provide informed consent, not acutely unwell, and proficient in the Shona language. We used a forward-backwards translation method to translate the EBBS from English to Shona, a native Zimbabwean language. After cross-cultural adaptation, we pretested the draft version in 10 PLHIV to assess the face validity, understandability and cultural appropriateness using semi-structured interviews. Thereafter, the EBBS was administered to 567 consecutively-selected PLHIV. Factor analyses were performed for construct validity evaluation.

Results

Most participants were female (72.5%) and reached secondary/high school (78.8%), with a mean age of 39.9 (SD 12.1) years. The EBBS-Shona version yielded a four-factor solution consisting of three benefits factors and one barrier factor against the originally postulated six-factor structure. The EBBS-Shona yielded α = 0.85 and intraclass correlation coefficient = 0.86, demonstrating excellent reliability. Increased perception of exercise benefits was positively correlated with increased reports of physical activity, higher health-related quality of life and lower psychiatric morbidity; evidence for construct validity.

Discussion

This study demonstrates the validity and reliability of the EBBS-Shona version in Zimbabwean PLHIV. The EBBS-Shona version can be used for research and clinical purposes to glean data to inform the development, implementation, and evaluation of bespoke PA interventions for PLHIV.

Reprioritising global mental health: psychoses in sub-Saharan Africa

Arthur Kleinman's 2009 Lancet commentary described global mental health as a "moral failure of humanity", asserting that priorities should be based not on the epidemiological and utilitarian economic arguments that tend to favour common mental health conditions like mild to moderate depression and anxiety, but rather on the human rights of those in the most vulnerable situations and the suffering that they experience. Yet more than a decade later, people with severe mental health conditions like psychoses are still being left behind. Here, we add to Kleinman's appeal a critical review of the literature on psychoses in sub-Saharan Africa, highlighting contradictions between local evidence and global narratives surrounding the burden of disease, the outcomes of schizophrenia, and the economic costs of mental health conditions. We identify numerous instances where the lack of regionally representative data and other methodological shortcomings undermine the conclusions of international research carried out to inform decision-making. Our findings point to the need not only for more research on psychoses in sub-Saharan Africa, but also for more representation and leadership in the conduct of research and in international priority-setting more broadly-especially by people with lived experience from diverse backgrounds. This paper aims to encourage debate about how this chronically under-resourced field, as part of wider conversations in global mental health, can be reprioritised.

Common mental health and emotional and behavioural disorders among adolescents and young adults in Harare and Mashonaland East, Zimbabwe: a population-based prevalence study

OBJECTIVES

To estimate the prevalence of common mental health disorders (CMDs) and emotional and behavioural disorders among young people and to explore the correlates of CMDs risk.

SETTING

Five urban and periurban communities in Harare and Mashonaland East, Zimbabwe DESIGN: Population-based cross-sectional study PARTICIPANTS: Young people aged 13-24 years living in households in the study areas.

OUTCOME MEASURES

The primary outcome was the proportion of participants screening positive for probable CMDs defined as a Shona Symptoms Questionnaire (SSQ) score ≥8. Secondary outcomes were emotional and behavioural disorders measured using the Strength and Difficulties Questionnaire (SDQ), and adjusted ORs for factors associated with CMD.

RESULTS

Out of 634 young people, 37.4% (95% CI 33.0% to 42.0%) screened positive for probable CMDs, 9.8% (95% CI 7.5% to 12.7%) reported perceptual symptoms and 11.2% (95% CI 9.0% to 13.8%) reported suicidal ideation. Using UK norms to define normal, borderline and abnormal scores for each of the SDQ domains, a high proportion (15.8%) of Zimbabwean young people had abnormal scores for emotional symptoms and a low proportion had abnormal scores for hyperactivity/inattention scores (2.8%) and prosocial scores (7.1%). We created local cut-offs for the emotional symptoms, hyperactivity/attention and prosocial SDQ domains. The odds of probable CMDs increased with each year of age (OR 1.09, p<0.001) and was higher among those who were out of school and not working compared with those in school or working (adj. OR 1.67 (1.07, 2.62), p=0.04). One in five participants (22.1%) were referred immediately for further clinical assessment but uptake of referral services was low.

CONCLUSIONS

We observed a high prevalence of symptoms of CMDs among general population urban and peri-urban young people especially among those with no employment. There is a need for more accessible and acceptable youth-friendly mental health services.

Prevalence of post-traumatic stress disorder and validity of the Impact of Events Scale - Revised in primary care in Zimbabwe, a non-war-affected African country

BACKGROUND

A critical step in research on the epidemiology of post-traumatic stress disorder (PTSD) in low-resource settings is the validation of brief self-reported psychometric tools available in the public domain, such as the Impact Event Scale - Revised (IES-R).

AIMS

We aimed to investigate the validity of the IES-R in a primary healthcare setting in Harare, Zimbabwe.

METHOD

We analysed data from a survey of 264 consecutively sampled adults (mean age 38 years; 78% female). We estimated the area under the receiver operating characteristic curve and sensitivity, specificity and likelihood ratios for different cut-off points of the IES-R, against a diagnosis of PTSD made using the Structured Clinical Interview for DSM-IV. We performed factor analysis to evaluate construct validity of the IES-R.

RESULTS

The prevalence of PTSD was 23.9% (95% CI 18.9-29.5). The area under the curve for the IES-R was 0.90. At a cut-off of ≥47, the sensitivity of the IES-R to detect PTSD was 84.1 (95% CI 72.7-92.1) and specificity was 81.1 (95% CI 75.0-86.3). Positive and negative likelihood ratios were 4.45 and 0.20, respectively. Factor analysis revealed a two-factor solution, with both factors showing good internal consistency (Cronbach's factor-1 α = 0.95, factor-2 α = 0.76). In a post hoc analysis, we found the brief six-item IES-6 also performed well, with an area under the curve of 0.87 and optimal cut-off of 15.

CONCLUSIONS

The IES-R and IES-6 had good psychometric properties and performed well for indicating possible PTSD, but at higher cut-off points than those recommended in the Global North.

The impact of working alliance in managing youth anxiety and depression: a scoping review

A working alliance (WA) is a multidimensional construct signifying a collaborative relationship between a client and a therapist. Systematic reviews of therapies to treat depression and anxiety, almost exclusively in adults, show WA is essential across psychotherapies. However, there are critical gaps in our understanding of the importance of WA in low-intensity therapies for young people with depression and anxiety. Here, we describe an initiative to explore the effect of WA on anxiety and depression outcomes in youth aged 14-24 years through a scoping review and stakeholders' consultations (N = 32). We analysed 27 studies; most were done in high-income countries and evaluated one-on-one in-person therapies (18/27). The review shows that optimal WA is associated with improvements in: relationships, self-esteem, positive coping strategies, optimism, treatment adherence, and emotional regulation. Young people with lived experience expressed that: a favourable therapy environment, regular meetings, collaborative goal setting and confidentiality were vital in forming and maintaining a functional WA. For a clinician, setting boundaries, maintaining confidentiality, excellent communication skills, being non-judgmental, and empathy were considered essential for facilitating a functional WA. Overall, a functional WA was recognised as an active ingredient in psychotherapies targeting anxiety and depression in young people aged 14-24. Although more research is needed to understand WA's influence in managing anxiety and depression in young people, we recommend routine evaluation of WA. Furthermore, there is an urgent need to identify strategies that promote WA in psychotherapies to optimise the treatment of anxiety and depression in young people.

The association of systemic inflammation and cognitive functions of pre-school aged children residing in a Schistosoma haematobium endemic area in Zimbabwe

Background

Cognitive function is negatively impacted by schistosomiasis and might be caused by systemic inflammation which has been hypothesized to be one of the mechanisms driving cognitive decline, This study explored the association of systemic inflammatory biomarkers; interleukin (IL)-10, IL-6, IL-17, transforming growth factor (TGF-β), tumor necrosis factor (TNF-α), C-reactive protein (CRP) and hematological parameters with cognitive performance of preschool-aged children (PSAC) from an Schistosoma haematobium endemic area.

Methods

The Griffith III tool was used to measure the cognitive performance of 136 PSAC. Whole blood and sera were collected and used to quantify levels of IL-10, TNF-α, IL-6, TGF-β, IL-17 A and CRP using the enzyme-linked immunosorbent assay and hematological parameters using the hematology analyzer. Spearman correlation analysis was used to determine the relationship between each inflammatory biomarker and cognitive performance. Multivariate logistic regression analysis was used to determine whether systemic inflammation due to S. haematobium infection affected cognitive performance in PSAC.

Results

Higher levels of TNF-α and IL-6, were correlated with lower performance in the Foundations of Learning domain (r = -0.30; p < 0.001 and r = -0.26; p < 0.001), respectively. Low cognitive performance in the Eye-Hand-Coordination Domain was observed in PSAC with high levels of the following inflammatory biomarkers that showed negative correlations to performance; TNF-α (r = -0.26; p < 0.001), IL-6 (r = -0.29; p < 0.001), IL-10 (r = -0.18; p < 0.04), WBC (r = -0.29; p < 0.001), neutrophils (r = -0.21; p = 0.01) and lymphocytes (r = -0.25; p = 0.003) The General Development Domain correlated with TNF-α (r = -0.28; p < 0.001) and IL-6 (r = -0.30; p < 0.001). TGF-β, L-17A and MXD had no significant correlations to performance in any of the cognitive domains. The overall general development of PSAC was negatively impacted by S. haematobium infections (OR = 7.6; p = 0.008) and (OR = 5.6; p = 0.03) where the PSAC had higher levels of TNF-α and IL-6 respectively.

Conclusion

Systemic inflammation and S. haematobium infections are negatively associated with cognitive function. We recommend the inclusion of PSAC into mass drug treatment programs.

HeAlth System StrEngThening in four sub-Saharan African countries (ASSET) to achieve high-quality, evidence-informed surgical, maternal and newborn, and primary care: protocol for pre-implementation phase studies

To achieve universal health coverage, health system strengthening (HSS) is required to support the of delivery of high-quality care. The aim of the National Institute for Health Research Global Research Unit on HeAlth System StrEngThening in Sub-Saharan Africa (ASSET) is to address this need in a four-year programme, with three healthcare platforms involving eight work-packages. Key to effective health system strengthening (HSS) is the pre-implementation phase of research where efforts focus on applying participatory methods to embed the research programme within the existing health system. To conceptualise the approach, we provide an overview of the key methods applied across work-package to address this important phase of research conducted between 2017 and 2021.Work-packages are being undertaken in publicly funded health systems in rural and urban areas in Ethiopia, Sierra Leone, South Africa, and Zimbabwe. Stakeholders including patients and their caregivers, community representatives, clinicians, managers, administrators, and policymakers are the main research participants.In each work-package, initial activities engage stakeholders and build relationships to ensure co-production and ownership of HSSIs. A mixed-methods approach is then applied to understand and address determinants of high-quality care delivery. Methods such as situation analysis, cross-sectional surveys, interviews and focus group discussions are adopted to each work-package aim and context. At the end of the pre-implementation phase, findings are disseminated using focus group discussions and participatory Theory of Change workshops where stakeholders from each work package use findings to select HSSIs and develop a programme theory.ASSET places a strong emphasis of the pre-implementation phase in order to provide an in-depth and systematic diagnosis of the existing heath system functioning, needs for strengthening and stakeholder engagement. This common approach will inform the design and evaluation of the HSSIs to increase effectiveness across work packages and contexts, to better understand what works, for whom, and how.

Stigma experienced by people living with HIV who are on methadone maintenance treatment and have symptoms of common mental disorders in Hanoi, Vietnam: a qualitative study

BACKGROUND

Stigma around human immunodeficiency virus (HIV), injection drug use (IDU), and mental health disorders can be co-occurring and have different impacts on the well-being of people living with HIV (PWH) who use drugs and have mental health disorders. This stigma can come from society, health professionals, and internalized stigma. A person who has more than one health condition can experience overlapping health-related stigma and levels of stigma which can prevent them from receiving necessary support and healthcare, serving to intensify their experience with stigma. This study investigates HIV, drug use, and mental health stigmas in three dimensions (social, internalized, and professional) around PWH on methadone maintenance treatment (MMT) who have common mental disorders (CMDs) including depression, anxiety, and stress-related disorders in Hanoi, Vietnam.Please check and confirm whether corresponding author's email id is correctly identified.The cooresponding author's email is correct METHODS: We conducted semi-structured, in-depth interviews (IDIs) (n = 21) and two focus group discussions (FGDs) (n = 10) with PWH receiving MMT who have CMD symptoms, their family members, clinic health care providers, and clinic directors. We applied thematic analysis using NVIVO software version 12.0, with themes based on IDI and FGD guides and emergent themes from interview transcripts.

RESULTS

The study found evidence of different stigmas towards HIV, IDU, and CMDs from the community, family, health care providers, and participants themselves. Community and family members were physically and emotionally distant from patients due to societal stigma around illicit drug use and fears of acquiring HIV. Participants often conflated stigmas around drug use and HIV, referring to these stigmas interchangeably. The internalized stigma around having HIV and injecting drugs made PWH on MMT hesitant to seek support for CMDs. These stigmas compounded to negatively impact participants' health.

CONCLUSIONS

Strategies to reduce stigma affecting PWH on MMT should concurrently address stigmas around HIV, drug addiction, and mental health. Future studies could explore approaches to address internalized stigma to improve self-esteem, mental health, and capacities to cope with stigma for PWH on MMT.

TRIAL REGISTRATION

NCT04790201, available at clinicaltrials.gov.

Task-sharing with lay counsellors to deliver a stepped care intervention to improve depression, antiretroviral therapy adherence and viral suppression in people living with HIV: a study protocol for the TENDAI randomised controlled trial

INTRODUCTION

Non-adherence to antiretroviral therapy (ART) is the main cause of viral non-suppression and its risk is increased by depression. In countries with high burden of HIV, there is a lack of trained professionals to deliver depression treatments. This paper describes the protocol for a 2-arm parallel group superiority 1:1 randomised controlled trial, to test the effectiveness and cost effectiveness of the TENDAI stepped care task-shifted intervention for depression, ART non-adherence and HIV viral suppression delivered by lay interventionists.

METHODS AND ANALYSIS

Two hundred and ninety people living with HIV aged ≥18 years with probable depression (Patient Health Questionnaire=>10) and viral non-suppression (≥ 1000 HIV copies/mL) are being recruited from HIV clinics in towns in Zimbabwe. The intervention group will receive a culturally adapted 6-session psychological treatment, Problem-Solving Therapy for Adherence and Depression (PST-AD), including problem-solving therapy, positive activity scheduling, skills to cope with stress and poor sleep and content to target barriers to non-adherence to ART. Participants whose score on the Patient Health Questionnaire-9 remains ≥10, and/or falls by less than 5 points, step up to a nurse evaluation for possible antidepressant medication. The control group receives usual care for viral non-suppression, consisting of three sessions of adherence counselling from existing clinic staff, and enhanced usual care for depression in line with the WHO Mental Health Gap intervention guide. The primary outcome is viral suppression (<1000 HIV copies/mL) at 12 months post-randomisation.

ETHICS AND DISSEMINATION

The study and its tools were approved by MRCZ/A/2390 in Zimbabwe and RESCM-18/19-5580 in the UK. Study findings will be shared through the community advisory group, conferences and open access publications.

TRIAL REGISTRATION NUMBER

NCT04018391.

Effect of Schistosoma haematobium infection on the cognitive functions of preschool age children and benefits of treatment from an endemic area in Zimbabwe

Background

Schistosomiasis is known to affect the cognitive functions of children, however, but there is paucity of information on its impact on early childhood development in developing countries where the disease is endemic. This study aimed at determining the effects of schistosomiasis due to Schistosoma haematobium on early childhood development in children below 5 years old from Murewa District, Zimbabwe, including the benefits of treatment.

Methods

Preschool age children (PSAC) under the age of 5 years were screened at baseline and at 6 months post-treatment for S. haematobium infections diagnosed using the urine filtration method. Cognitive domains were assessed using the Griffith Mental Developmental Scales III on 136 PSAC. Multivariate logistic regression was used to determine the level of association between S. haematobium infection and performance in the cognitive domains adjusting for confounding factors (i.e. nutrition, hemoglobin levels, gender and age). Median Development Quotient scores of each cognitive domain at baseline and at 6 months post-treatment were compared and quantified.

Results

After adjusting for confounding factors, PSAC infected with S. haematobium had greater odds of having lower scores in the Foundation of Learning Domain (OR = 3.9, p = 0.008), Language and Communication Domain (OR = 3.2, p = 0.017), Eye-Hand Coordination Domains (OR = 10.7, p = 0.001), Personal-Social-Emotional Domain (19.3, p = 0.001) and in the Overall General Development Domain (7.2, p = 0.011). Improvement of cognitive performance was observed at 6 months post treatment in the following Domains; Language and Communication Domain (p = 0.003), Eye-Hand Coordination Domain (p = 0.02) and General Development Domain (p = 0.006).

Conclusion

The study showed that S. haematobium infection in PSAC is associated with lower cognitive scores in the Foundation of Learning, Language and Communication, Eye-Hand Coordination, Personal-Social-Emotional and in the Overall General Development domains. Our results strengthen the call for inclusion of PSAC in routine deworming programs for the control of urinary schistosomiasis and the need to develop locally validated tools to monitor early child development in endemic areas where resources are limited.

A Digital Mental Health Intervention (Inuka) for Common Mental Health Disorders in Zimbabwean Adults in Response to the COVID-19 Pandemic: Feasibility and Acceptability Pilot Study

BACKGROUND

Common mental health disorders (CMDs) are leading causes of disability globally. The ongoing COVID-19 pandemic has further exacerbated the burden of CMDs. COVID-19 containment measures, including lockdowns, have disrupted access to in-person mental health care. It is therefore imperative to explore the utility of digital mental health interventions to bridge the treatment gap. Mobile health technologies are effective tools for increasing access to treatment at a lower cost. This study explores the utility of Inuka, a chat-based app hinged on the Friendship Bench problem-solving therapy intervention. The Inuka app offers double anonymity, and clients can book or cancel a session at their convenience. Inuka services can be accessed either through a mobile app or the web.

OBJECTIVE

We aimed to explore the feasibility of conducting a future clinical trial. Additionally, we evaluated the feasibility, acceptability, appropriateness, scalability, and preliminary effectiveness of Inuka.

METHODS

Data were collected using concurrent mixed methods. We used a pragmatic quasiexperimental design to compare the feasibility, acceptability, and preliminary clinical effectiveness of Inuka (experimental group) and WhatsApp chat-based counseling (control). Participants received 6 problem-solving therapy sessions delivered by lay counselors. A reduction in CMDs was the primary clinical outcome. The secondary outcomes were health-related quality of life (HRQoL), disability and functioning, and social support. Quantitative outcomes were analyzed using descriptive and bivariate statistics. Finally, we used administrative data and semistructured interviews to gather data on acceptability and feasibility; this was analyzed using thematic analysis.

RESULTS

Altogether, 258 participants were screened over 6 months, with 202 assessed for eligibility, and 176 participants were included in the study (recruitment ratio of 29 participants/month). The participants' mean age was 24.4 (SD 5.3) years, and most participants were female and had tertiary education. The mean daily smartphone usage was 8 (SD 3.5) hours. Eighty-three users signed up and completed at least one session. The average completion rate was 3 out of 4 sessions. Inuka was deemed feasible and acceptable in the local context, with connectivity challenges, app instability, expensive mobile data, and power outages cited as potential barriers to scale up. Generally, there was a decline in CMDs (F_2,73=2.63; P=.08), depression (F_2,73=7.67; P<.001), and anxiety (F_2,73=2.95; P=.06) and a corresponding increase in HRQoL (F_2,73=7.287; P<.001) in both groups.

CONCLUSIONS

Study outcomes showed that it is feasible to run a future large-scale randomized clinical trial (RCT) and lend support to the feasibility and acceptability of Inuka, including evidence of preliminary effectiveness. The app's double anonymity and structured support were the most salient features. There is a great need for iterative app updates before scaling up. Finally, a large-scale hybrid RCT with a longer follow-up to evaluate the clinical implementation and cost-effectiveness of the app is needed.

Adolescent Health Series The status of adolescent mental health research, practice and policy in sub-Saharan Africa: A narrative review

Sub‐Saharan Africa (SSA) has the fastest growing adolescent population in the world. In addition to developmental changes, adolescents in SSA face health and socioeconomic challenges that increase their vulnerability to mental ill‐health. This paper is a narrative review of adolescent mental health (AMH) in SSA with a focus on past achievements, current developments, and future directions in the areas of research, practice and policy in the region. We describe the status of AMH in the region, critical factors that negatively impact AMH, and the ways in which research, practice and policy have responded to this need. Depression, anxiety and post‐traumatic stress disorders are the most common mental health problems among adolescents in SSA. Intervention development has largely been focused on HIV/AIDS service delivery in school or community programs by non‐specialist health workers. There is a severe shortage of specialised AMH services, poor integration of services into primary health care, lack of a coordinated inter‐sectoral collaboration, and the absence of clear referral pathways. Policies for the promotion of AMH have been given less attention by policymakers, due to stigma attached to mental health problems, and an insufficient understanding of the link between mental health and social determinants, such as poverty. Given these gaps, traditional healers are the most accessible care available to help‐seeking adolescents. Sustained AMH research with a focus on the socioeconomic benefits of implementing evidence‐based, contextually adapted psychosocial interventions might prove useful in advocating for much needed policies to improve AMH in SSA.

Adaptation of a Problem-solving Program (Friendship Bench) to Treat Common Mental Disorders Among People Living With HIV and AIDS and on Methadone Maintenance Treatment in Vietnam: Formative Study

Background

The prevalence of common mental disorders (CMDs) among people living with HIV and people who inject drugs is high worldwide and in Vietnam. However, few evidence-informed CMD programs for people living with HIV who inject drugs have been adapted for use in Vietnam. We adapted the Friendship Bench (FB), a problem-solving therapy (PST)–based program that was successfully implemented among patients with CMDs in primary health settings in Zimbabwe and Malawi for use among people living with HIV on methadone maintenance treatment (MMT) with CMDs in Hanoi, Vietnam.

Objective

This study aimed to describe the adaptation process with a detailed presentation of 4 phases from the third (adaptation) to the sixth (integration) of the Assessment-Decision-Adaptation-Production-Topical Experts-Integration-Training-Testing (ADAPT-ITT) framework.

Methods

The adaptation phase followed a qualitative study design to explore symptoms of CMDs, facilitators, and barriers to conducting FB for people living with HIV on MMT in Vietnam, and patient, provider, and caretaker concerns about FB. In the production phase, we revised the original program manual and developed illustrated PST cases. In the topical expert and integration phases, 2 investigators (BNG and BWP) and 3 subject matter experts (RV, DC, and GML) reviewed the manual, with reviewer comments incorporated in the final, revised manual to be used in the training. The draft program will be used in the training and testing phases.

Results

The study was methodologically aligned with the ADAPT-ITT goals as we chose a proven, effective program for adaptation. Insights from the adaptation phase addressed the who, where, when, and how of FB program implementation in the MMT clinics. The ADAPT-ITT framework guided the appropriate adaptation of the program manual while maintaining the core components of the PST of the original program throughout counseling techniques in all program sessions. The deliverable of this study was an adapted FB manual to be used for training and piloting to make a final program manual.

Conclusions

This study successfully illustrated the process of operationalizing the ADAPT-ITT framework to adapt a mental health program in Vietnam. This study selected and culturally adapted an evidence-informed PST program to improve CMDs among people living with HIV on MMT in Vietnam. This adapted program has the potential to effectively address CMDs among people living with HIV on MMT in Vietnam.

Trial Registration

ClinicalTrials.gov NCT04790201; https://clinicaltrials.gov/ct2/show/NCT04790201

Factors motivating female sex workers to initiate pre- exposure prophylaxis for HIV prevention in Zimbabwe

Background

Female sex workers (FSWs) have a 26 times greater chance of HIV infection compared to the women in the general population. The World Health Organization recommends pre-exposure prophylaxis (PrEP) for population groups with an HIV incidence of 3% or higher and FSWs in southern Africa fit this criteria. This study sought to understand factors that motivate FSWs to initiate PrEP, in Harare, Zimbabwe.

Methods

We purposively selected and recruited 20 FSWs to participate in the study in-order to gain an in-depth understanding of factors that motivate FSWs to initiate PrEP in Harare, Zimbabwe. We identified FSW who had been initiated on PrEP at a specialized clinic providing comprehensive sexual reproductive health (SRH) services for sex workers including HIV prevention options. We used a descriptive phenomenological approach to collect and analyze the data. Data was analyzed using Colaizzi’s seven steps to analyze data.

Findings

Two broad themes were identified as intrinsic and extrinsic motivators. The two broad themes each have several sub-themes. The sub-themes under intrinsic motivation were (i) Self- protection from HIV infection and (ii) condoms bursting. Six sub-themes were identified as external motivators for initiating PrEP, these included (i) occupational risk associated with sex work, (ii) increased chance of offering unprotected sex as a motivator to initiate PrEP, (iii) positive encouragement from others (iv) need to take care of the children and (v) prior participation in HIV prevention research studies and (vi) Gender Based Violence.

Conclusions

Understanding the factors that motivate FSWs to initiate PrEP is critical in developing contextually appropriate strategies to promote PrEP initiation and adherence strategies within specific and eligible populations for receiving PrEP according to the WHO guidelines (2015).

Barriers to the provision of non-communicable disease care in Zimbabwe: a qualitative study of primary health care nurses

Background

Non-communicable diseases (NCDs) contribute significantly to the global disease burden, with low-and middle-income (LMICs) countries disproportionately affected. A significant knowledge gap in NCDs exacerbates the high burden, worsened by perennial health system challenges, including human and financial resources constraints. Primary health care workers play a crucial role in offering health care to most people in LMICs, and their views on the barriers to the provision of quality care for NCDs are critical. This study explored perceived barriers to providing NCDs care in primary health care facilities in Zimbabwe.

Methods

In-depth, individual semi-structured interviews were conducted with general nurses in primary care facilities until data saturation was reached. We focused on diabetes, hypertension, and depression, the three most common conditions in primary care in Zimbabwe. We used thematic content analysis based on an interview guide developed following a situational analysis of NCDs care in Zimbabwe and views from patients with lived experiences.

Results

Saturation was reached after interviewing 10 participants from five busy urban clinics. For all three NCDs, we identified four cross-cutting barriers, a) poor access to medication and functional equipment such as blood pressure machines, urinalysis strips; b) high cost of private care; c)poor working conditions; and d) poor awareness from both patients and the community which often resulted in the use of alternative potentially harmful remedies. Participants indicated that empowering communities could be an effective and low-cost approach to positive lifestyle changes and health-seeking behaviours. Participants indicated that the Friendship bench, a task-shifting programme working with trained community grandmothers, could provide a platform to introduce NCDs care at the community level. Also, creating community awareness and initiating screening at a community level through community health workers (CHWs) could reduce the workload on the clinic nursing staff.

Conclusion

Our findings reflect those from other LMICs, with poor work conditions and resources shortages being salient barriers to optimal NCDs care at the facility level. Zimbabwe's primary health care system faces several challenges that call for exploring ways to alleviate worker fatigue through strengthened community-led care for NCDs. Empowering communities could improve awareness and positive lifestyle changes, thus optimising NCD care. Further, there is a need to optimise NCD care in urban Zimbabwe through a holistic and multisectoral approach to improve working conditions, basic clinical supplies and essential drugs, which are the significant challenges facing the country's health care sector. The Friendship Bench could be an ideal entry point for providing an integrated NCD care package for diabetes, hypertension and depression.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00841-1.

Peer-led counselling with problem discussion therapy for adolescents living with HIV in Zimbabwe: A cluster-randomised trial

BACKGROUND

Adolescents living with HIV have poor virological suppression and high prevalence of common mental disorders (CMDs). In Zimbabwe, the Zvandiri adolescent peer support programme is effective at improving virological suppression. We assessed the effect of training Zvandiri peer counsellors known as Community Adolescent Treatment Supporters (CATS) in problem-solving therapy (PST) on virological suppression and mental health outcomes.

METHODS AND FINDINGS

Sixty clinics were randomised 1:1 to either normal Zvandiri peer counselling or a peer counsellor trained in PST. In January to March 2019, 842 adolescents aged 10 to 19 years and living with HIV who screened positive for CMDs were enrolled (375 (44.5%) male and 418 (49.6%) orphaned of at least one parent). The primary outcome was virological nonsuppression (viral load ≥1,000 copies/mL). Secondary outcomes were symptoms of CMDs measured with the Shona Symptom Questionnaire (SSQ ≥8) and depression measured with the Patient Health Questionnaire (PHQ-9 ≥10) and health utility score using the EQ-5D. The adjusted odds ratios (AORs) and 95% confidence intervals (CIs) were estimated using logistic regression adjusting for clinic-level clustering. Case reviews and focus group discussions were used to determine feasibility of intervention delivery. At baseline, 35.1% of participants had virological nonsuppression and 70.3% had SSQ≥8. After 48 weeks, follow-up was 89.5% for viral load data and 90.9% for other outcomes. Virological nonsuppression decreased in both arms, but there was no evidence of an intervention effect (prevalence of nonsuppression 14.7% in the Zvandiri-PST arm versus 11.9% in the Zvandiri arm; AOR = 1.29; 95% CI 0.68, 2.48; p = 0.44). There was strong evidence of an apparent effect on common mental health outcomes (SSQ ≥8: 2.4% versus 10.3% [AOR = 0.19; 95% CI 0.08, 0.46; p < 0.001]; PHQ-9 ≥10: 2.9% versus 8.8% [AOR = 0.32; 95% CI 0.14, 0.78; p = 0.01]). Prevalence of EQ-5D index score <1 was 27.6% versus 38.9% (AOR = 0.56; 95% CI 0.31, 1.03; p = 0.06). Qualitative analyses found that CATS-observed participants had limited autonomy or ability to solve problems. In response, the CATS adapted the intervention to focus on empathic problem discussion to fit adolescents' age, capacity, and circumstances, which was beneficial. Limitations include that cost data were not available and that the mental health tools were validated in adult populations, not adolescents.

CONCLUSIONS

PST training for CATS did not add to the benefit of peer support in reducing virological nonsuppression but led to improved symptoms of CMD and depression compared to standard Zvandiri care among adolescents living with HIV in Zimbabwe. Active involvement of caregivers and strengthened referral structures could increase feasibility and effectiveness.

TRIAL REGISTRATION

Pan African Clinical Trials Registry PACTR201810756862405.

Economic threshold analysis of delivering a task-sharing treatment for common mental disorders at scale: the Friendship Bench, Zimbabwe

Background

Task-sharing treatment approaches offer a pragmatic approach to treating common mental disorders in low-income and middle-income countries (LMICs). The Friendship Bench (FB), developed in Zimbabwe with increasing adoption in other LMICs, is one example of this type of treatment model using lay health workers (LHWs) to deliver treatment.

Objective

To consider the level of treatment coverage required for a recent scale-up of the FB in Zimbabwe to be considered cost-effective.

Methods

A modelling-based deterministic threshold analysis conducted within a ‘cost-utility’ framework using a recommended cost-effectiveness threshold.

Findings

The FB would need to treat an additional 3413 service users (10 per active LHW per year) for its scale-up to be considered cost-effective. This assumes a level of treatment effect observed under clinical trial conditions. The associated incremental cost-effectiveness ratio was $191 per year lived with disability avoided, assuming treatment coverage levels reported during 2020. The required treatment coverage for a cost-effective outcome is within the level of treatment coverage observed during 2020 and remained so even when assuming significantly compromised levels of treatment effect.

Conclusions

The economic case for a scaled-up delivery of the FB appears convincing in principle and its adoption at scale in LMIC settings should be given serious consideration.

Clinical implications

Further evidence on the types of scale-up strategies that are likely to offer an effective and cost-effective means of sustaining required levels of treatment coverage will help focus efforts on approaches to scale-up that optimise resources invested in task-sharing programmes.

Optimising implementation strategies of the first scaleup of a primary care psychological intervention for common mental disorders in Sub-Saharan Africa: a mixed methods study protocol for the optimised Friendship Bench (OptFB)

INTRODUCTION

Common mental disorders (CMDs) are a leading cause of disability globally. CMDs are highly prevalent in Zimbabwe and have been addressed by an evidence-based, task-shifting psychological intervention called the Friendship Bench (FB). The task-shifted FB programme guides clients through problem-solving therapy. It was scaled up across 36 implementation sites in Zimbabwe in 2016.

METHODS AND ANALYSIS

This study will employ a mixed-method framework. It aims to: (1) use quantitative survey methodologies organised around the Reach, Effectiveness, Adoption and Implementation and Maintenance evaluation framework to assess the current scaleup of the FB intervention and classify 36 clinics according to levels of performance; (2) use qualitative focus group discussions and semistructured interviews organised around the Consolidated Framework for Implementation Research to analyse determinants of implementation success, as well as elucidate heterogeneity in implementation strategies through comparing high-performing and low-performing clinics; and (3) use the results from aims 1 and 2 to develop strategies to optimise the Friendship Bench intervention and apply this model in a cluster randomised controlled trial to evaluate potential improvements among low-performing clinics. The trial will be registered with the Pan African Clinical Trial Registry (www.pactr.org). The planned randomised controlled trial for the third research aim will be registered after completing aims one and two because the intervention is dependent on knowledge generated during these phases.

ETHICS AND DISSEMINATION

The research protocol received full authorisation from the Medical Research Council of Zimbabwe (MRCZ A/242). It is anticipated that changes in data collection tools and consent forms will take place at all three phases of the study and approval from MRCZ will be sought. All interview partners will be asked for informed consent. The research team will prioritise open-access publications to disseminate research results.

Using a theory of change to develop an integrated intervention for depression, diabetes and hypertension in Zimbabwe: lessons from the Friendship Bench project

BACKGROUND

Non-communicable diseases (NCDs) are projected to become the leading cause of disability and mortality in sub-Saharan Africa by 2030; a vast treatment gap exists. There is a dearth of knowledge on developing evidence-based interventions that address comorbid NCDs using a task-shifting approach. The Friendship Bench, a brief psychological intervention for common mental disorders delivered by trained community grandmothers, is a promising intervention for comorbid NCDs. Although task-shifting appears to be a rational approach, evidence suggests that it may bring about tension between existing professionals from whom tasks are shifted. A Theory of Change approach is an effective way of managing the unintended tension by bringing together different stakeholders involved to build consensus on how to task shift appropriately to the parties involved. We aimed to use a theory of change approach to formulating a road map on how to successfully integrate diabetes and hypertension care into the existing Friendship Bench in order to come up with an integrated care package for depression, hypertension and diabetes aimed at strengthening NCD care in primary health care systems in Zimbabwe.

METHOD

A theory of change workshop with 18 stakeholders from diverse backgrounds was carried out in February 2020. Participants included grandmothers working on the Friendship Bench project (n = 4), policymakers from the ministry of health (n = 2), people with lived experience for the three NCDs (n = 4), health care workers (n = 2), and traditional healers (n = 2). Findings from earlier work (situational analysis, desk review, FGDs and clinic-based surveys) on the three NCDs were shared before starting the ToC. A facilitator with previous experience running ToCs led the workshop and facilitated the co-production of the ToC map. Through an iterative process, consensus between the 18 stakeholders was reached, and a causal pathway leading to developing a framework for an intervention was formulated.

RESULTS

The ToC singled out the need to use expert clients (people with lived experience) to promote a patient-centred care approach that would leverage the existing Friendship Bench approach. In the face of COVID-19, the stakeholders further endorsed the use of existing digital platforms, notably WhatsApp, as an alternative way to reach out to clients and provide support. Leveraging existing community support groups as an entry point for people in need of NCD care was highlighted as a win-win by all stakeholders. A final framework for an NCD care package supported by Friendship Bench was presented to policymakers and accepted to be piloted in five geographical areas.

CONCLUSIONS

The ToC can be used to build consensus on how best to use using an existing intervention for common mental disorders to integrate care for diabetes and hypertension. There is a need to evaluate this new intervention through an adequately powered study.

Potential Resilience to Post-traumatic Stress Disorder and Common Mental Disorders among Lay Health Workers Working on the Friendship Bench Programme in Zimbabwe

PURPOSE

The Friendship Bench is a successful task-shifting intervention for addressing common mental disorders in Zimbabwe. The intervention takes a cognitive behavioural therapy and problem-solving approach provided by lay health workers (LHWs). The LHWs live in the same environment as their clients and are thus exposed to the same traumas and stressors as are their clients. Little is known about the long-term psychological effects on LHWs involved in this type of work.

METHODS

A random sample of LHWs (n=182) was assessed using the Posttraumatic Stress Disorder Checklist (PCL-5) and the Shona Symptom Questionnaire (SSQ-14), both locally validated.

RESULTS

The prevalence of PTSD and CMD was low among all surveyed LHWs. Eleven (6%) and 17 (11%) presented with probable PTSD and CMD, respectively.

CONCLUSION

Despite living and working in the same settings as their clients, the Friendship Bench LHWs show good mental health outcomes.

Assessing early child development and its association with stunting and schistosome infections in rural Zimbabwean children using the Griffiths Scales of Child Development

There is a paucity of reference early childhood development (ECD) data at community level in rural Africa. Our objective was to conduct a comprehensive assessment of ECD in rural Zimbabwe and determine the impact of stunting and schistosome infections on ECD. Using the Griffiths Scales of Child Development, we conducted a cross sectional assessment of Eye and Hand Coordination (EHC), Personal-Social-Emotional (PSE), Language and Communication (LC), Foundations of Learning (FL) and Gross Motor (GM) domains and the summary General Development (GD) in 166 children aged 6-72 months. The effects of stunting, malnutrition and Schistosoma haematobium infection on ECD was determined. The impact of praziquantel curative treatment of schistosome infection on the developmental scores was determined through a longitudinal follow up at 6 and 12 months. From an initial 166 children, 11 were found to have developmental deficits warranting further investigation. Of the remaining 155, 58.7% recorded a good (≥ average) score for the overall General Development (GD). Proportions of children scoring above the cut-off (≥ average) for each domain were GM (84.5%), PSE (80.6%), EHC (61.9%), FL (43.9%) and LC (44.5%). The prevalence of stunting was 26.8% (95% CI = 20.1%-34.8%) Scores for stunted children were significantly lower for EHC (p = 0.0042), GM (p = 0.0099), and GD (p = 0.0014) with the fraction of lower scores attributable to stunting being GM = 63.4%, GD = 46.6%, EHC = 45%, and LC = 21%. S. haematobium infection prevalence was 39.7% and mean infection intensity was 5.4 eggs/10 ml urine. Infected children had poorer cognitive performance scores for the FL (p = 0.0005) with 30.8% of poor FL attributable to the infection. Performance in all domains improved to the expected normal or above reference levels at 6 and 12 months post curative treatment of schistosome infections. Our study documented reference values for ECD in rural Zimbabwean children. The study detected deficiencies in the FL domain, which were more pronounced in children, infected with schistosomes, highlighting the need for provision of cognitive stimulation tools and access to early childhood foundation education. There is also need for improved child nutrition and treatment of schistosome infections to improve child development outcomes.

Risk factors for HIV virological non-suppression among adolescents with common mental disorder symptoms in Zimbabwe: a cross-sectional study

INTRODUCTION

Adolescents are at increased risk of HIV virological non-suppression compared to adults and younger children. Common mental disorders such as anxiety and depression are a barrier to adherence and virological suppression. The aim of this study was to identify factors associated with virological non-suppression among adolescents living with HIV (ALWH) in Zimbabwe who had symptoms of common mental disorders.

METHODS

We utilized baseline data from a cluster-randomized controlled trial of a problem-solving therapy intervention to improve mental health and HIV viral suppression of ALWH. Sixty clinics within 10 districts were randomized 1:1 to either the intervention or control arm, with the aim to recruit 14 adolescents aged 10 to 19 per clinic. Adolescents were eligible if they scored ≥7 on the Shona Symptom Questionnaire measuring symptoms of common mental disorders. Multivariable mixed-effects logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (95% CI) for factors associated with non-suppression, defined as viral load ≥1000 copies/mL.

RESULTS

Between 2 January and 21 March 2019 the trial enrolled 842 participants aged 10 to 19 years (55.5% female, 58.8% aged <16). Most participants (N = 613) were taking an NNRTI-based ART regimen (13 PI-based, 216 unknown) and median duration on ART was six years (IQR three to nine years, 240 unknown). Of the 833 with viral load data 292 (35.1%) were non-suppressed. Virological non-suppression was independently associated with male sex (adjusted OR (aOR) = 1.43, 95% CI 1.04 to 1.97), and with not knowing one's own HIV status (aOR = 1.77, 95% CI 1.08 to 2.88), or knowing one's status but not disclosing it to anyone (aOR = 1.99, 95% CI 1.36 to 2.93), compared to adolescents who knew their status and had disclosed it to someone.

CONCLUSIONS

ALWH with symptoms of common mental disorders have high prevalence of virological non-suppression in Zimbabwe, especially if they do not know their status or have not disclosed it. In general adolescents should be informed of their HIV status, with encouragement on the beneficial health and social effects of viral suppression, to incentivise adherence. Efforts to strengthen the operationalization of disclosure guidelines for adolescents should now be prioritized.

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.

Impact of Friendship Bench problem-solving therapy on adherence to ART in young people living with HIV in Zimbabwe: A qualitative study

BACKGROUND

Adolescents and young people globally are highly vulnerable to poor mental health especially depression, and they account for 36% of new HIV infections in Eastern and Southern Africa. HIV services remain inadequate for this population and their adherence to ART is low. The Friendship Bench (FB), an evidence-based model developed in Zimbabwe to bridge the mental health gap, is a brief psychological intervention delivered on benches in primary care facilities by lay health workers ("grandmothers") trained in problem-solving therapy. This study explored the experience of young people living with HIV attending FB, and their perception of how problem-solving therapy impacted their adherence to ART.

METHODS

Semi-structured interviews were conducted in July 2019 with 10 young people living with HIV aged 18-24 years, who had recently completed FB counselling in Harare. Participants were purposively sampled and recruited from three primary care facilities. Interviews were conducted in Shona, audio-recorded, transcribed verbatim and translated into English. Transcripts were analysed in NVivo12 using inductive thematic analysis.

RESULTS

Study findings revealed a clear emotional denial towards HIV, particularly for young people infected perinatally, and a resulting low adherence to ART. The study also unpacked the issues of internal stigma and how young people living with perinatally acquired HIV are informed of their HIV status. Participants reported that FB had a critical role in helping them accept their HIV status. Grandmothers' empathic attitude was key during counselling on adherence to ART, to demystify the disease and treatment, normalize the reality of living with HIV, encourage young people to socialize with peers and free them of guilt. Interviewees unanimously reported improved ART adherence following FB counselling, and many described enhanced health and wellbeing.

CONCLUSION

Participants saw FB as a strong contributor to their general well-being, evident in decreased symptoms of depression and improved adherence to ART. FB problem-solving therapy should be rolled out to further support young people after post-test counselling or HIV serostatus disclosure for perinatally acquired HIV, for acceptance of HIV status and adherence to ART.

A community health volunteer delivered problem-solving therapy mobile application based on the Friendship Bench 'Inuka Coaching' in Kenya: A pilot cohort study

BACKGROUND

Sub-Saharan Africa (SSA) has the largest care gap for common mental disorders (CMDs) globally, heralding the use of cost-cutting approaches such as task-shifting and digital technologies as viable approaches for expanding the mental health workforce. This study aims to evaluate the effectiveness of a problem-solving therapy (PST) intervention that is delivered by community health volunteers (CHVs) through a mobile application called 'Inuka coaching' in Kenya.

METHODS

A pilot prospective cohort study recruited participants from 18 health centres in Kenya. People who self-screened were eligible if they scored 8 or higher on the Self-Reporting Questionnaire-20 (SRQ-20), were aged 18 years or older, conversant in written and spoken English, and familiar with the use of smart mobile devices. The intervention consisted of four PST mobile application chat-sessions delivered by CHVs. CMD measures were administered at baseline, 4-weeks (post-treatment), and at 3-months follow-up assessment.

RESULTS

In all, 80 participants consented to the study, of which 60 participants (female, n = 38; male, n = 22) completed their 4-week assessments, and 52 participants completed their 3-month follow-up assessment. The results showed a significant improvement over time on the Self-Reporting Questionnaire-20 (SRQ-20). Higher-range income, not reporting suicidal ideation, being aged over 30 years, and being male were associated with higher CMD symptom reduction.

CONCLUSION

To our knowledge, this report is the first to pilot a PST intervention that is delivered by CHVs through a locally developed mobile application in Kenya, to which clinically meaningful improvements were found. However, a randomised-controlled trial is required to robustly evaluate this intervention.

It helps to talk: A guiding framework (TRUST) for peer support in delivering mental health care for adolescents living with HIV

INTRODUCTION

Adolescents living with HIV have poor treatment outcomes, including lower rates of viral suppression, than other age groups. Emerging evidence suggests a connection between improved mental health and increased adherence. Strengthening the focus on mental health could support increased rates of viral suppression. In sub-Saharan Africa clinical services for mental health care are extremely limited. Additional mechanisms are required to address the unmet mental health needs of this group. We consider the role that community-based peer supporters, a cadre operating at scale with adolescents, could play in the provision of lay-support for mental health.

METHODS

We conducted qualitative research to explore the experiences of peer supporters involved in delivering a peer-led mental health intervention in Zimbabwe as part of a randomized control trial (Zvandiri-Friendship Bench trial). We conducted 2 focus group discussions towards the end of the trial with 20 peer supporters (aged 18-24) from across 10 intervention districts and audio recorded 200 of the peer supporters' monthly case reviews. These data were thematically analysed to explore how peer supporters reflect on what was required of them given the problems that clients raised and what they themselves needed in delivering mental health support.

RESULTS

A primary strength of the peer support model, reflected across the datasets, is that it enables adolescents to openly discuss their problems with peer supporters, confident that there is reciprocal trust and understanding derived from the similarity in their lived experiences with HIV. There are potential risks for peer supporters, including being overwhelmed by engaging with and feeling responsible for resolving relationally and structurally complex problems, which warrant considerable supervision. To support this cadre critical elements are needed: a clearly defined scope for the manageable provision of mental health support; a strong triage and referral system for complex cases; mechanisms to support the inclusion of caregivers; and sustained investment in training and ongoing supervision.

CONCLUSION

Extending peer support to explicitly include a focus on mental health has enormous potential. From this empirical study we have developed a framework of core considerations and principles (the TRUST Framework) to guide the implementation of adequate supportive infrastructure in place to enhance the opportunities and mitigate risks.

Effectiveness of a psychological intervention delivered by general nurses for alcohol use disorders in people living with HIV in Zimbabwe: a cluster randomized controlled trial

INTRODUCTION

There have been very few randomized clinical trials of interventions for alcohol use disorders (AUD) in people living with HIV (PLWH) in African countries. This is despite the fact that alcohol use is one of the modifiable risk factors for poor virological control in PLWH on antiretroviral therapy.

METHODS

Sixteen clinic clusters in Zimbabwe were selected through stratified randomization and randomized 1: 1 to Intervention and Control arms. Inclusion criteria for individual participants were being adult, living with HIV and a probable alcohol use disorder as defined by a score of 6 (women) or 7 (men) on the Alcohol Use Disorders Identification Test (AUDIT). In the Intervention clusters, participants received 8 to 10 sessions of Motivational Interviewing blended with brief Cognitive Behavioural Therapy (MI-CBT). In the control clusters, participants received four Enhanced Usual Care (EUC) sessions based on the alcohol treatment module from the World Health Organisation mhGAP intervention guide. General Nurses from the clinics were trained to deliver both treatments. The primary outcome was a change in AUDIT score at six-month post-randomization. Viral load, functioning and quality of life were secondary outcomes. A random-effects analysis-of-covariance model was used to account for the cluster design.

RESULTS

Two hundred and thirty-four participants (n = 108 intervention and n = 126 control) were enrolled across 16 clinics. Participants were recruited from November 2016 to November 2017 and followed through to May 2018. Their mean age was 43.3 years (SD = 9.1) and 78.6% (n = 184) were male. At six months, the mean AUDIT score fell by -6.15 (95% CI -6.32; -6.00) in the MI-CBT arm, compared to a fall of - 3.09 95 % CI - 3.21; -2.93) in the EUC arm (mean difference -3.09 (95% CI -4.53 to -1.23) (p = 0.05). Viral load reduced and quality of life and functioning improved in both arms but the difference between arms was non-significant.

CONCLUSIONS

Interventions for hazardous drinking and AUD comprising brief, multiple alcohol treatment sessions delivered by nurses in public HIV facilities in low-income African countries can reduce problematic drinking among PLWH. Such interventions should be integrated into the primary care management of AUD and HIV and delivered by non-specialist providers. Research is needed on cost-effectiveness and implementation of such interventions, and on validation of cut-points for alcohol use scales in low resource settings, in partnership with those with lived experience of HIV and AUD.

Developing sustainable capacity-building in mental health research: implementation outcomes of training of trainers in systematic reviewing

Less than 1% of biomedical research papers originate in Africa. Locally relevant mental health research, including synthesis of existing evidence, is essential for developing interventions and strengthening health systems, but institutions may lack the capacity to deliver training on systematic reviewing for publication in international journals. This paper describes the development and implementation of a training-of-trainers (ToT) course on systematic reviewing. The ToT prepared junior faculty (‘trainers’) from universities in Ethiopia, Malawi, and Zimbabwe to lead a five-day systematic reviewing workshop. Using an evaluation framework based on implementation science outcomes, the feasibility of the ToT was assessed by tracking the number of workshops the trainers subsequently conducted and the number of trainers and trainees who participated; acceptability was assessed through post-workshop surveys on trainee perspectives; impact was evaluated through trainee scores on a 15-item multiple choice test on systematic reviewing concepts; and sustainability was assessed based on whether the workshop was integrated into university curricula. Twelve trainers (86% of those trained) facilitated a total of seven workshops in their home countries (total 103 trainees). The first workshop run in each country was evaluated, and there was a significant improvement in mean knowledge scores between pre- and post-tests among trainees (MD= 3.07, t= 5.90, 95% CI 2.02–4.11). In two of the three countries, there are efforts to integrate the systematic review workshop into university curricula. The cost of the workshop led by the international trainer was $1480 per participant, whereas the trainer-led workshops cost approximately $240 per participant. Overall, ToT is relatively new to research capacity building, although it has been used widely in clinical settings. Our findings suggest ToT is a promising, low-cost way to develop both technical skills of individuals and the pedagogical capacity of universities, and to promote sustainability of research capacity building programs that often have time-limited grant funding.

Effectiveness of a peer-led adolescent mental health intervention on HIV virological suppression and mental health in Zimbabwe: protocol of a cluster-randomised trial

BACKGROUND

Adolescents living with HIV (ALHIV) experience a high burden of mental health disorder which is a barrier to antiretroviral therapy adherence. In Zimbabwe, trained, mentored peer supporters living with HIV (Community Adolescent Treatment Supporters - CATS) have been found to improve adherence, viral suppression and psychosocial well-being among ALHIV. The Friendship Bench is the largest integrated mental health programme in Africa. We hypothesise that combining the CATS programme and Friendship Bench will improve mental health and virological suppression among ALHIV compared with the CATS programme alone.

METHODS

We will conduct a cluster-randomised controlled trial in 60 clinics randomised 1:1 in five provinces. ALHIV attending the control arm clinics will receive standard CATS support and clinic support following the Ministry of Health guidelines. Those attending the intervention arm clinics will receive Friendship Bench problem-solving therapy, delivered by trained CATS. Participants with the signs of psychological distress will be referred to the clinic for further assessment and management. The primary outcome is HIV virological failure (≥1000 copies/ml) or death at 48 weeks. Secondary outcomes include the proportion of adolescents with common mental disorder symptoms (defined as Shona Symptom Questionnaire (SSQ-14) score ≥8), proportion with depression symptoms (defined as Patient Health Questionnaire (PHQ-9) score ≥11), symptom severity (mean SSQ-14 and PHQ-9 scores) and EQ-5D score for health-related quality of life.

CONCLUSIONS

This trial evaluates the effectiveness of peer-delivery of mental health care on mental health and HIV viral load among ALHIV. If effective this intervention has the potential to be scaled-up to improve these outcomes.Trial registration: PACTR201810756862405. 08 October 2018.

"We need more big trees as well as the grass roots": going beyond research capacity building to develop sustainable careers in mental health research in African countries

BACKGROUND

There are substantial gaps in our knowledge regarding the aetiology of mental, neurological and substance use disorders in sub-Saharan Africa, and the cost-effectiveness and scalability of interventions to reduce the burden of these conditions on the continent. To address these gaps, international investment has focussed on building research capacity, including funding doctoral students in African countries, to support development of high quality, contextually relevant interventions. Absent, however, is an understanding of how capacity building feeds into research careers.

METHODS

Within a broader mental health research capacity-building initiative (African Mental Health Research Initiative), we conducted 52 qualitative interviews with early-career researchers, policymakers, academics, and service users from four African countries (Ethiopia, Malawi, South Africa, and Zimbabwe) and with international funders of mental health research. The interview guide focused on the research context, planning, and priorities and how respondents perceive research careers and funding. Thematic analysis was applied to the transcribed interviews.

RESULTS

Five components of a research career emerged: (i) research positions; (ii) research skills; (iii) funding; (iv) research commitment from African countries; and (v) advocacy. All stakeholders wanted more high-impact African researchers, but few saw a clear, replicable track for developing their careers within universities or their Ministries of Health in their African countries. This stemmed, in part, from the lack of support for infrastructure that enables high-quality research: grants administration, mentorship, university leadership, research culture, and open communication between policymakers and researchers.

CONCLUSIONS

This study highlights the importance of developing research infrastructure alongside capacity-building efforts. International funders should invest in grant management at African universities which would place them at the centre of research initiatives. African universities should prioritise the creation of a research culture by developing and promoting well-defined research tracks for both clinicians and academics, investing in grant management, and raising the profile of research within their institutions.

Poor mental health of livestock farmers in Africa: a mixed methods case study from Ghana

Background

Agriculture represents the mainstay of African economies and livestock products are essential to the human population’s nutritional needs. However, in many developing countries, including Ghana, livestock production fails to meet demand due to population growth and negative effects of climate change. One of the challenges to production is livestock loss affecting farmers. However, despite stressful events experienced, livestock farmers’ mental health is poorly documented. This study aims to identify the root causes of livestock losses and their influence on pastoralists’ mental health.

Methods

We conducted a mixed methods study in two districts in the Northern and Southern Belts of Ghana. Using the Depression Anxiety and Stress Scale–21 and guided interviews, we collected quantitative and qualitative data from 287 livestock farmers and 24 key-informants respectively. Mental health scores were categorized using standard guidelines. We evaluated the factors that explained variations in mental wellbeing using general linear models (α = 0.05).

Results

About 85% (240/287) of the livestock farmers lost cattle within 1 year. Of these, 91% lost cattle to animal diseases, 50% to theft and 27% to pasture shortages. Qualitative findings reveal that due to poor access to veterinary services, farmers treat livestock diseases themselves with drugs from unregulated sources and often sell diseased cows for meat to recover losses. Findings showed that 60% of livestock farmers had poor mental health. Of those, 72% were depressed, 66% anxious and 59% stressed. Mental wellbeing was negatively associated with the number of adverse events experienced, proportion of livestock lost to most of the major loss factors, emotional attachment to livestock and self-reported physical illnesses in farmers, but positively associated with increasing herd size [F (8,278) = 14.18, p < 0.001, R² = 0.29].

Conclusions

Livestock diseases are the leading cause of losses to livestock farmers, whose mental wellbeing is negatively affected by these losses. Although an adaptive strategy by farmers to compensate for poor veterinary services, the arbitrary use of veterinary drugs and sale of diseased cattle pose health risks to the public. Further research to evaluate the performance of veterinary services in Ghana, mental health problems and risk to human health due to potential high-risk meat entering the food chain, is needed.

The effect of co-morbid anxiety on remission from depression for people participating in a randomised controlled trial of the Friendship Bench intervention in Zimbabwe

BACKGROUND

There is a lack of data from low- and middle-income countries on whether anxiety independently predicts a more chronic course for depression.

METHODS

We undertook secondary data analysis of a cluster randomised controlled trial in Zimbabwe which had tested the effectiveness of the Friendship Bench intervention for common mental disorders compared to enhanced usual care. Inclusion for the current study was participants from the trial who had probable major depression at baseline, defined as scoring => 11 on the locally validated Patient Health Questionnaire (PHQ9). This emerged to be 354 of the original 573 (61.78%) of the original trial sample. Anxiety was measured using the locally validated cut-point on the Generalised Anxiety Disorder scale (GAD-7). Persistent depression was defined as scoring => 11 on the PHQ-9 at six-months follow-up. Analysis in Stata 15 used random-effects logistic regression to adjust for clustering by clinic.

OUTCOMES

Of the 354 participants who were eligible for treatment, 329 (92·9%) completed 6-month follow-up assessment. 37% of the trial sample had persistent depression at 6-months follow-up; 59% in the control arm and 17% in the intervention arm. Co-morbid anxiety present at trial baseline was independently associated with persistent depression after adjusting for age, gender and baseline depression severity (adjusted OR = 2·83, 95% CI 1·32-6·07). There was no evidence of effect modification by trial arm. Baseline depression severity also predicted persistent depression. Interpretation Treatment for depression in low and middle-income countries (LMIC) should be directed towards those with greatest need. This includes people with co-morbid anxiety and greater depression severity at initial assessment who are less likely to remit at six months. Advice on coping with anxiety, psychological treatments which target common anxiety symptoms such as fear, avoidance, excessive worry and intrusive thoughts, and Selective Serotonin Reuptake Inhibitors (SSRIs) should be made more widely available in LMIC and offered to those with persistent mixed depression and anxiety.

Neurocognitive impairment in treatment-experienced adults living with HIV attending primary care clinics in Zimbabwe

Background

HIV affects the central nervous system resulting in HIV associated neurocognitive impairment (NCI) in approximately 50% of people living with HIV. It typically affects memory, learning, working memory, fine motor skills, speed of information processing, verbal fluency and executive functioning cognitive domains. NCI can affect adherence to antiretroviral therapy (ART), employability, driving ability and activities of daily living. NCI is not routinely screened for in Zimbabwe, and the burden is not known in this setting. The objectives of this study were: 1) To determine NCI prevalence using a comprehensive neuropsychological battery at two primary health care clinics in Harare; 2) To assess the pattern of cognitive impairment across cognitive domains using a gold standard neuropsychological (NP) battery in HIV-positive patients compared to HIV-negative controls.

Methods

Inclusion criteria: 18 years or older; minimum 7 years education; no neurological or psychiatric disorders. HIV-positive participants were on ART for ≥3 months; HIV-negative participants had a confirmed HIV negative status in the past month. A comprehensive NP battery, functional assessments, demographic and medical history questionnaires were administered. The NP battery consisted of tests assessing memory, learning, working memory, fine motor skills, speed of information processing, verbal fluency and executive functioning.

Results

Two-hundred-and-thirty-one participants were recruited. Of those, 155 were HIV-positive (Female = 70%, Age M = 37.8; SD 11.2) and 76 HIV-negative (Female = 63%, Age M = 31.2; SD 9.9). HIV-positive participants were on ART for an average of 6 years. NCI was present in 49.7% HIV positive participants. Compared to HIV-negative participants, the HIV-positive group had significantly poorer scores in 5 out of 7 cognitive domains. A good level of education is negatively correlated with NCI.

Conclusions

NCI prevalence in HIV-positive population Zimbabwe is consistent with global estimates. NCI persists in adults who are on ART. Routine assessment of NCI in adults attending primary care clinics using this adapted battery is therefore important so that they are identified early and are provided the necessary interventions.

The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi

BACKGROUND

Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical.

METHODS

A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group.

RESULTS

Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)].

CONCLUSIONS

While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.

Mental health research capacity building in sub-Saharan Africa: the African Mental Health Research Initiative

Mental, neurological and substance use (MNS) disorders are a leading, but neglected, cause of morbidity and mortality in sub-Saharan Africa. The treatment gap for MNS is vast with only 10% of people with MNS disorders in low-income countries accessing evidence-based treatments. Reasons for this include low awareness of the burden of MNS disorders and limited evidence to support development, adaptation and implementation of effective and feasible treatments. The overall goal of the African Mental Health Research Initiative (AMARI) is to build an African-led network of MNS researchers in Ethiopia, Malawi, South Africa and Zimbabwe, who are equipped to lead high quality mental health research programs that meet the needs of their countries, and to establish a sustainable career pipeline for these researchers with an emphasis on integrating MNS research into existing programs such as HIV/AIDS. This paper describes the process leading to the development of AMARI's objectives through a theory of change workshop, successes and challenges that have been faced by the consortium in the last 4 years, and the future role that AMARI could play in further building MNS research capacity by brining on board more institutions from low- and middle-income countries with an emphasis on developing an evidence-based training curriculum and a research-driven care service.

Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis

OBJECTIVES

Depression symptom questionnaires are not for diagnostic classification. Patient Health Questionnaire-9 (PHQ-9) scores ≥10 are nonetheless often used to estimate depression prevalence. We compared PHQ-9 ≥10 prevalence to Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) major depression prevalence and assessed whether an alternative PHQ-9 cutoff could more accurately estimate prevalence.

STUDY DESIGN AND SETTING

Individual participant data meta-analysis of datasets comparing PHQ-9 scores to SCID major depression status.

RESULTS

A total of 9,242 participants (1,389 SCID major depression cases) from 44 primary studies were included. Pooled PHQ-9 ≥10 prevalence was 24.6% (95% confidence interval [CI]: 20.8%, 28.9%); pooled SCID major depression prevalence was 12.1% (95% CI: 9.6%, 15.2%); and pooled difference was 11.9% (95% CI: 9.3%, 14.6%). The mean study-level PHQ-9 ≥10 to SCID-based prevalence ratio was 2.5 times. PHQ-9 ≥14 and the PHQ-9 diagnostic algorithm provided prevalence closest to SCID major depression prevalence, but study-level prevalence differed from SCID-based prevalence by an average absolute difference of 4.8% for PHQ-9 ≥14 (95% prediction interval: -13.6%, 14.5%) and 5.6% for the PHQ-9 diagnostic algorithm (95% prediction interval: -16.4%, 15.0%).

CONCLUSION

PHQ-9 ≥10 substantially overestimates depression prevalence. There is too much heterogeneity to correct statistically in individual studies.