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 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. Victoria Simms and co-workers report on a trial of problem discussion therapy for adolescents with HIV infection and common mental disorders in Zimbabwe. Author summary Why was this study done? Common mental disorders (CMDs) such as anxiety and depression are highly prevalent among adolescents living with HIV. It is important to identify strategies to treat CMDs in this population. The Friendship Bench is a proven effective mental health intervention based on problem-solving therapy (PST), which is delivered by trained lay counsellors. The Zvandiri programme is a proven effective intervention to improve HIV outcomes among adolescents, delivered by trained peer counsellors. It is not known whether PST could improve mental health, and HIV outcomes, among adolescents living with HIV, when delivered in addition to the Zvandiri programme. What did the researchers do and find? We conducted a trial among 842 adolescents living with HIV in Zimbabwe, who also had CMDs (depression and anxiety), and attended public health clinics for HIV care. We randomly allocated 30 clinics to provide Zvandiri peer counselling to adolescents living with HIV, and a further 30 clinics to provide Zvandiri counselling plus the Friendship Bench PST. After a year, there was no difference in the proportion with unsuppressed HIV viral load, and this was low in both groups. There was a substantial improvement in mental health (depression and anxiety) in both groups, with significantly better outcomes among those in the Friendship Bench group. The peer counsellors adapted their training and focused on problem discussion rather than problem-solving, because many adolescents identified problems that they did not have the resources to solve. What do these findings mean? To our knowledge, this is the first study to show that an intervention can improve mental health among adolescents living with HIV who have mental health disorders. The lack of an impact on HIV viral load, compared to the Zvandiri programme, might be because of the effectiveness of the Zvandiri counselling and the presence of resistance to HIV drugs in a small number of participants. Mental healthcare should be integrated in HIV care for adolescents. It should be age specific, with shorter sessions than for adults, creating a space for discussing and sharing problems, and involving caregivers as appropriate.