Effect of a Psychological Intervention on Antiretroviral Therapy and Mental Health Outcomes in HIV-positive Adults in Zimbabwe

Common mental disorders are highly prevalent among people living with HIV. Left untreated, common mental disorders cause substantial disability and undermine individuals' ability to adhere to antiretroviral therapy, leading to poor antiretroviral therapy outcomes.

A recent cluster-randomized controlled trial from Harare, Zimbabwe showed that the friendship bench intervention (i.e. six sessions of problem-solving therapy delivered by lay health workers followed by a peer support group) effectively reduced symptoms of common mental disorders, but the effect of the intervention on antiretroviral therapy outcomes and its effectiveness in the rural setting has not been studied.

To examine the effect of the friendship bench intervention on antiretroviral therapy outcomes and symptoms of common mental disorders among adults living with HIV and common mental disorders in rural Zimbabwe, a cluster-randomized trial is conducted.

• Friendship bench intervention (Behavioral): The friendship bench intervention consists of six individual counseling sessions and a peer-led group activity. Individual counseling is based on problem-solving therapy and delivered by lay health workers. During individual counseling, participants will be actively encouraged to identify and tackle problems leading to sub-optimal antiretroviral therapy adherence. In the group activity, participants are taught an income generating skill and have the opportunity to share personal experience with former participants of the intervention.
• Enhanced Standard of Care (Other): Study participants receive information on available routine services for common mental disorders, a nurse-led brief support counseling, assessment for antidepressant medication (fluoxetine) by the clinic nurse, and referral to a psychiatric facility if needed, in addition to the standard of care provided according to national antiretroviral therapy guidelines.

Primary outcomes

• Average difference in mean antiretroviral therapy adherence between 2 and 6 months [2-6 months]: Adherence will be calculated as percentage of prescribed doses taken and measured with the Medication Event Monitoring System (MEMS)

Secondary outcomes

• Difference in mean antiretroviral therapy adherence between 1 and 12 months [1-12 months]: Adherence will be calculated as percentage of prescribed doses taken and measured with the Medication Event Monitoring System (MEMS)
• Difference in change from baseline in Shona Symptoms Questionnaire (SSQ-14) score [At month 3, 6, 9, and 12]: The Shone Symptoms Questionnaire is a 14 item tool. The reported total score is between 0 and 14. 14 is the highest level of mental disorder. Each item adds a score of 0 or 1 to the total score.
• Difference in change from baseline in Patient Health Questionnaire (PHQ-9) score [At month 3, 6, 9, and 12]: The Patient Health Questionnaire is a 9 item tool. The reported total score is between 0 and 27. 27 is the highest level of depression. Each item adds a score of 0 to 3 to the total score.
• Viral load suppression (<1000 copies per milliliter) [At month 6 (i.e., day 180 ± 90 days) and month 12 (i.e., day 360 ± 90 days)]: Categorical (yes, no, invalid or missing).

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Age ≥18 years
* Use of first-line antiretroviral therapy for at least 6 months
* Resident in Bikita District
* Knowledge of English or Shona language
* Ability to comprehend the information on the study
* Positive screening for common mental disorders (SSQ-14 score ≥9)
* Providing informed consent

Exclusion Criteria:

* Current psychosis / cognitive impairment
* Clinical AIDS (WHO clinical stage 4)
* Known pregnancy or ≤3 months postpartum

• Results publication: Haas AD, Kunzekwenyika C, Manzero J, Hossmann S, Limacher A, van Dijk JH, Manhibi R, von Groote P, Hobbins MA, Verhey R, Egger M; Friendship Bench ART trial group. Effect of the Friendship Bench Intervention on Antiretroviral Therapy Outcomes and Mental Health Symptoms in Rural Zimbabwe: A Cluster Randomized Trial. JAMA Netw Open. 2023 Jul 3;6(7):e2323205. doi: 10.1001/jamanetworkopen.2023.23205. PMID 37440230
• Results publication: Haas AD, Kunzekwenyika C, Manzero J, Hossmann S, Limacher A, van Dijk JH, Manhibi R, von Groote P, Hobbins MA, Verhey R, Egger M; Friendship Bench ART trial group. Effect of the Friendship Bench intervention on antiretroviral therapy outcomes and mental health symptoms in rural Zimbabwe: A cluster randomized trial. medRxiv [Preprint]. 2023 Jan 22:2023.01.21.23284784. doi: 10.1101/2023.01.21.23284784. PMID 36711671
• Results publication: Haas AD, Kunzekwenyika C, Hossmann S, Manzero J, van Dijk J, Manhibi R, Verhey R, Limacher A, von Groote PM, Manda E, Hobbins MA, Chibanda D, Egger M; IeDEA Southern Africa. Symptoms of common mental disorders and adherence to antiretroviral therapy among adults living with HIV in rural Zimbabwe: a cross-sectional study. BMJ Open. 2021 Jul 7;11(7):e049824. doi: 10.1136/bmjopen-2021-049824. PMID 34233999

• Andreas D Haas, PhD, Principal investigator, Institute of Social and Preventive Medicine (ISPM), University of Bern
• Cordelia Kunzekwenyika, MD, Principal investigator, SolidarMed, Swiss Organisation for Health in Africa