Group support psychological therapy led by lay health workers is effective at alleviating symptoms of major depression among HIV-positive adults, according to research conducted in rural Uganda. Aidsmap reports that researchers found rates of depression and overall function were much better among people who participated in the psychotherapy sessions compared to individuals enrolled in sessions providing general HIV information.
Moreover, group psychotherapy had benefits in terms of symptoms of post-traumatic stress disorder (PTSD), hazardous alcohol consumption, suicide risk, self-esteem and HIV-related stigma. The intervention was also calculated to be highly cost-effective.
“Study findings indicate that it is possible to overcome barriers of poverty, remoteness, mental health stigma, and cultural ignorance to provide a comprehensive HIV care model to people living with HIV in rural areas,” comment the investigators. “Lay health workers delivering group support psychotherapy for depression care within routine primary care in a low-resource setting might have the potential to accelerate attainment of the UNAIDS 90-90-90 targets.”
The prevalence of depression and other mental health disorders among people living with HIV in sub-Saharan Africa is estimated between 13% and 78%, far higher than rates observed in the general population. HIV treatment programmes in the region do not generally include mental health screening. For low- and middle-income countries, the World Health Organisation recommends talking therapies as first-line therapy for depression. However, there is a lack of information on their effectiveness and cost-effectiveness for people with HIV.
Dr Etheldreda Nakimuli-Mpungu of Makerere University, Kampala and colleagues wanted to see if group psychotherapy sessions led by lay health workers were an effective treatment for depression in HIV-positive adults with mild to moderate depression.
In an accompanying editorial comment, Dr Eirini Karyotaki and Dr John Naslund, at the department of global health and social medicine, Harvard Medical School, suggest the study adds “compelling evidence” of the cost-effectiveness of treating depression among people living with HIV in low- and middle-income countries.
They conclude: “These findings open new research avenues for mental health care of people living with HIV, and to addressing the major challenges posed by comorbid depression with HIV for individuals in society, especially in low- and middle-income countries where speciality mental health providers are scarce.”
Background: WHO recommends the use of psychological interventions as first-line treatment for depression in low-income and middle-income countries. However, evaluations of the effectiveness and cost-effectiveness of such interventions among people with HIV are scarce. Our aim was to establish the effectiveness of group support psychotherapy (GSP) delivered by lay health workers for depression treatment among people living with HIV in a rural area of Uganda on a large scale.
Methods: In this cluster-randomised trial, we included 30 health centres offering HIV care. These were randomly assigned to deliver either GSP or group HIV education (GHE). Randomisation, in a ratio of 1:1, was achieved by health centre managers separately picking a paper containing the intervention allocation from a basket. Participants were people living with HIV, aged 19 years and older, with mild to moderate major depression assessed with the Mini International Neuropsychiatric Interview depression module, taking antiretroviral therapy, and antidepressant-naive. Group sessions were led by trained lay health workers once a week for 8 weeks. The primary outcomes were the proportion of participants with major depression and function scores at 6 months post-treatment, analysed by intention to treat by means of multilevel random effect regression analyses adjusting for clustering in health centres. This trial is registered with the Pan African Clinical Trials Registry, PACTR201608001738234.
Findings: Between Sept 13 and Dec 15, 2016, we assessed 1473 individuals, of whom 1140 were recruited from health centres offering GSP (n=578 [51%]) or GHE (n=562 [49%]). Two (<1%) participants in the GSP group were diagnosed with major depression 6 months post-treatment compared with 160 (28%) in the GHE group (adjusted odds ratio=0·01, 95% CI 0·003–0·012, p<0·0001). The mean function scores 6 months post-treatment were 9·85 (SD 0·76) in the GSP group and 6·83 (2·85) in the GHE group (β=4·12; 95% CI 3·75–4·49, p<0·0001). 36 individuals had 63 serious adverse events, which included 25 suicide attempts and 22 hospital admissions for medical complications. The outcomes of these serious adverse events included 16 deaths, 4 of which were completed suicides (GSP=2; GHE=2), and 12 of which were HIV-related medical complications (GSP=8; GHE=4). Cost-effectiveness estimates showed an incremental cost-effectiveness ratio of US$13·0 per disability-adjusted life-year averted, which can be considered very cost-effective in Uganda.
Interpretation: Integration of cost-effective psychological treatments such as group support psychotherapy into existing HIV interventions might improve the mental health of people living with HIV.
Funding: MQ Transforming Mental Health and Grand Challenges Canada.
Etheldreda Nakimuli-Mpungu, Seggane Musisi, Kizito Wamala, James Okello, Sheila Ndyanabangi, Josephine Birungi, Mastula Nanfuka, Micheal Etukoit, Chrispus Mayora, Freddie Ssengooba, Ramin Mojtabai, Jean B Nachega, Ofir Harari, Edward J Mills