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

Abstract

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.

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

“…Two of the three trials examined virologic suppression (this study and the trial among adolescents 44 ), and both failed to demonstrate any statistically significant effect ( eFigure 1 in Supplement 3 ). The present study also examined adherence and equally showed no robust intervention effect.…”

“…44 Of note, differences in SSQ-14 and PHQ-9 scores were relatively small, with about 1 score point difference favoring the intervention at 48 weeks. 44…”

“…The third trial included adolescents living with HIV and symptoms of CMDs in Zimbabwe. 44 The intervention improved symptoms of CMDs and depression compared to standard care among adolescents living with HIV in Zimbabwe. 44 Of note, differences in SSQ-14 and PHQ-9 scores were relatively small, with about 1 score point difference favoring the intervention at 48 weeks.…”

Data-informed stepped care to improve youth engagement in HIV care in Kenya: a protocol for a cluster randomised trial of a health service intervention

“…Our multicomponent intervention is based on a combination of evidence-based interventions and recommended but untested strategies to clearly allocate services using a pre-specified algorithm/tool to tailor specific services for AYLHIV. [55][56][57][58][59] Services include individual motivational interviewing to preemptively improve retention, CBT to address depressive symptoms, and enhanced counselling for adherence. System improvements include facility quality improvement and guideline refreshers.…”

Prioritizing the mental health needs of pregnant adolescents in sub-Saharan Africa

“…A cluster randomized trial in Zimbabwe evaluated the effectiveness of training community adolescent peer counsellors in problem-solving therapy on mental health outcomes observed improved symptoms of common mental disorder and depression. 52 The effectiveness of peer support programmes as demonstrated in Zimbabwe was so significant such that the country became the first (and perhaps only) to adopt peer support models into its national health system. 53 It is also important that policies are instituted to protect and support pregnant teenagers.…”