The Effect of Group Support Psychotherapy Delivered by Trained Lay Health Workers for Depression Treatment Among People with HIV in Uganda: Protocol of a Pragmatic, Cluster Randomized Trial.

Etheldreda Nakimuli-Mpungu,James Okello,Sheila Ndyanabangi,Kizito Wamala,Jean Nachega,Seggane Musisi,Edward Mills,Ramin Mojtabai,Ofir Harari

doi:10.2196/resprot.8925

Abstract

BackgroundThere is limited information on the effectiveness of task shifting of mental health services in populations with HIV.ObjectiveThis trial aims to evaluate the effectiveness of group support psychotherapy delivered by trained lay health workers to persons living with HIV (PLWH) with depression in primary care.MethodsThirty eligible primary care health centers across three districts were randomly allocated to have their lay health workers trained to deliver group support psychotherapy (intervention arm) or group HIV education and treatment as usual (control arm) to PLWH with depression. Treated PLWH will be evaluated at baseline, after the end of treatment, and at 6-month intervals thereafter for 2 years. Primary outcomes will be the difference in follow-up proportions of participants with Mini International Neuropsychiatric Interview criteria for major depression and difference in follow-up function scores of participants in the intervention and control arms 6 months after the end of treatment. Secondary outcomes will include measures of self-esteem, posttraumatic stress symptoms, social support, stigma, adherence to antiretroviral therapy, viral load, and number of disability days, asset possession indices, and cost-effectiveness data. Primary and secondary outcomes as well as subgroup analyses will be conducted at the individual level using multilevel random effects regression analyses adjusting for clustering in health centers. A process evaluation using mixed methods to assess acceptability, feasibility, fidelity, causal mediating processes, and contextual influences in the trial will be conducted.ResultsThe trial has been approved by the Makerere College of Health Sciences School of Health Sciences Research Ethics Committee, the AIDS Support Organization, and the Uganda National Council of Science and Technology. A data and safety monitoring board has been put in place to monitor trial progress. A total of 1140 persons living with HIV have been recruited to the trial. An analysis of baseline and 6-month data is in progress. The results of this trial will not only be presented at national and international conferences but also submitted for publication in peer-reviewed journals and as a report to the funding agencies.ConclusionsThis cluster randomized trial will provide critical evidence to support culturally sensitive group-based psychotherapy for depression treatment in sub-Saharan Africa. Process evaluation outcomes will provide contextual information that health care and public health stakeholders can use to guide implementation decisions for their particular setting.Trial RegistrationPan African Clinical Trials Registry (PACTR): 201608001738234; http://www.pactr.org/ATMWeb/ appmanager/atm/atmregistry?dar=true&tNo=PACTR201608001738234 (Archived by WebCite at http://www.webcitation.org/ 6vUAgAQlj)

Highlights

A total of 1140 persons living with HIV have been recruited to the trial
In the fight against the HIV epidemic over the past three decades, one of the major barriers to universal access to health care needed by persons living with HIV (PLWH) has been a serious shortage of health workers to deliver these interventions [1]
The shortage of well-trained health workers to address the myriad biological, social, and psychological challenges of living with HIV poses a risk for suboptimal HIV treatment outcomes, in sub-Saharan African countries where the burden of HIV and acquired immune deficiency syndrome (AIDS) is greatest [2]

Summary

Introduction

In the fight against the HIV epidemic over the past three decades, one of the major barriers to universal access to health care needed by persons living with HIV (PLWH) has been a serious shortage of health workers to deliver these interventions [1]. Affected individuals continue to struggle with poor health, social, and economic outcomes because depression impairs their ability to function in their families, at work, and in their communities [5,6]. This, in turn, has resulted in the development and testing of a number of psychological interventions for depression that can be used in poor resource areas where the gap between the availability and need for mental health services [8,9,10], known as the “treatment gap,” may be as high as 90% [11]. Accessibility and sustainability of these interventions is impeded by the severe shortage of mental health professionals who can deliver them to affected individuals who need them [12].

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