Preliminary communicationA group-based counselling intervention for depression comorbid with HIV/AIDS using a task shifting approach in South Africa: A randomized controlled pilot study
Introduction
With the transition of HIV to a chronic condition in South Africa with the rapid roll-out of anti-retroviral therapy (ART), increasing attention is being paid to factors that can compromise adherence in order to protect the huge investment in ART. One of these factors is comorbid depression. Internationally, the relationship between depression and poor ART adherence is confirmed by a meta-analysis of 35,029 participants (Gonzalez et al., 2011). This relationship holds in sub-Saharan Africa as well, with a recent review indicating that HIV-positive patients with depressive symptoms are 55% less likely to be adherent than HIV-positive patients without depressive symptoms (Nakimuli-Mpungu et al., 2012). This is in the face of evidence of a twofold increased risk for depression if HIV-positive (Ciesla and Roberts, 2001).
In the context of having one of the largest ART programmes in the world, inadequate treatment of co-morbid depression in ART patients poses a public health threat to South Africa. Yet, to date, scant attention has been paid to this issue with only one in four people with common mental disorders (CMDs), including depression, having access to treatment of any kind (Seedat et al., 2009).
In their systematic review assessing the effectiveness of different types of interventions that target depression in people living with HIV/AIDS (PLWHA), Sherr et al. found that interventions that used either psychological interventions with a cognitive behavioural component or psychotropic drugs were effective, with a combination of the two types of interventions being the most effective (Sherr et al., 2011). However, the applicability of the findings of this review to low- and middle-income countries and South Africa in particular, is questionable given that it presents data mainly from high income countries (Sherr et al., 2011). A recent review of psychological treatments of evidence-based treatments indicates, however, that they are as effective in populations for which they were not originally developed if adapted for the local context (Chowdhary et al., 2013). Given the paucity of mental health specialists in South Africa, there is a need to adopt a task shifting approach whereby specialist tasks are shared with general health care providers. A review of counselling interventions for treating depression in LMICs using a task shifting approach, found that in addition to medication, there was evidence of the effectiveness of cognitive-behavioural therapy (CBT), interpersonal therapy (IPT) and problem-solving therapy (PST) (Dua et al., 2011).
South Africa has adopted a new Mental Health Care Policy Framework (Department of Health, 2013) which requires that mental health services are integrated into PHC services a part of the shift towards integrated disease management for chronic illnesses, including HIV. To this end, an integrated task shifting is embraced with an integrated set of clinical guidelines, including mhGAP guidelines for mental disorders, being rolled out to PHC facilities in South Africa. While these guidelines assist nurses and doctors to identify and provide symptom management to patients with mental disorders, they do not provide guidelines for intensive counselling defined by mhGAP as taking a few hours of a health care provider׳s time to learn and implement (World Health Organisation, 2010).
Lay HIV counsellors, historically funded by the United States President׳s Emergency Plan for AIDS Relief (PEPFAR) to provide health counselling and testing (HCT), are based in most primary health care (PHC) clinics in South Africa. A recent review of research on their use in South Africa suggests, inter alia, that they have the potential to provide more intensive counselling within a task shifting approach but that more evidence of their effectiveness in this regard is required (Petersen et al., in press).
The aim of this study was thus to conduct a pilot randomized control trial (RCT) to evaluate the potential effectiveness of an adapted group-based HIV counsellor delivered intervention for treating depression in people living with HIV/AIDS in preparation for a larger trial. The intervention was adapted from an existing IPT group-based intervention for the general population, previously found to have promising outcomes in South Africa (Petersen et al., 2012).
Section snippets
Study site
The study was conducted at a public clinic in the KwaZulu-Natal province in a peri-urban area outside of Durban in the eThekwini district, situated on the eastern seaboard of South Africa. During 2012/2013, the province had seven of the ten worst affected districts in South Africa, with the eThekwini districts having one of the highest HIV prevalence of pregnant women living with HIV in the country at 40% (Massyn et al., 2013). At the time of the study the clinic served about 800 people on ART
Description of the sample
Loss to follow up was high and the study was only able to follow-up 49% of the original sample at post evaluation assessment. Data from a total of 34 participants (17 in the intervention arm and 17 in the control arm) were included in the final analysis (see Fig. 1 for flow chart of study participants). The demographics of the sample are depicted in Table 3. Chi-square (χ2) analysis did not reveal any significant differences in demographic characteristics between the intervention and control
Discussion
The outcomes of this pilot randomized control trial shows a significant reduction in depressive symptoms in PLWHA with comorbid depression in the intervention group compared to those in receipt of normal standard of care. Notwithstanding low uptake and high loss to follow-up, these preliminary results suggest that using lay HIV counsellors to deliver manualized group-based counselling to treat depression in PLWHA holds potential as an effective and acceptable strategy for closing the treatment
Limitations of the study
Despite efforts to ensure an adequately powered sample, the poor uptake of the intervention in the intervention arm and loss to follow up among patients in the control arm resulted in a small sample size affecting the power of study results. For service delivery this highlights the need to find mechanisms to address patient difficulties in attending group counselling sessions such as providing individual counselling as an option; combining clinic visits with the delivery of counselling
Conclusion
Despite the significant challenges faced in the field with retention and recruitment, these findings are encouraging and suggest that group-based counselling for depression in PLWHA can potentially be effectively delivered by appropriately trained and supported lay HIV counsellors. The study adds to the evidence that appropriately adapted psychological treatments for depression can be effective on populations for whom they were not originally developed (Chowdhary et al., 2013) and that lay
Role of funding source
This document is an output from a project funded by the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal, South Africa.
Conflict of interest
None to declare.
Acknowledgements
The authors would like to acknowledge the help of One Selohilwe for the development of the training manual and supervising the training as well as the following students and research assistants in conducting the training, supervision and assistance in the collection of the data: Nolita Mchunu, Nombeko Mahlangu, Philile Mngade, Sindi Shezi, Philile Makhaya, Neliswa Vungwana, Phephelani Zondi, Sduduzo Mncwabe, Kirsten Clark, Mary Rogers, Vanessa Wright, Jonelle du Plessis, Waheeda Goga, Nhunhu
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