Comparing dedicated and designated approaches to integrating task-shared psychological interventions into chronic disease care in South Africa: a three-arm, cluster randomised, multicentre, open-label trial.

BACKGROUND: Community health workers (CHWs) are increasingly providing task-shared psychological interventions for depression and alcohol use in primary health care in low-income and middle-income countries. We aimed to compare the effectiveness of CHWs dedicated to deliver care with CHWs designated to deliver care over and above their existing responsibilities and with treatment as usual for patients with a chronic physical disease. METHODS: We did a three-arm, cluster randomised, multicentre, open-label trial done in 24 primary health-care clinics (clusters) within the Western Cape province of South Africa. Clinics were randomly assigned (1:1:1) to implement dedicated care, designated care, or treatment as usual, stratified by urban-rural status. Patients with HIV or type 1 or type 2 diabetes were eligible if they were 18 years old or older, taking antiretroviral therapy for HIV or medication to manage their diabetes, had an Alcohol Use Disorders Identification Test (AUDIT) score of eight or more or a Center for Epidemiologic Studies Depression Scale score of 16 or more, and were not receiving mental health treatment. In the intervention arms, all participants were offered three sessions of an evidence-based psychological intervention, based on motivational interviewing and problem-solving therapy, delivered by CHWs. Our primary outcomes were depression symptom severity and alcohol use severity, which we assessed separately for the intention-to-treat populations of people with HIV and people with diabetes cohorts and in a pooled cohort, at 12 months after enrolment. The Benjamini-Hochberg procedure was used to adjust for multiple testing. The trial was prospectively registered with the Pan African Clinical Trials Registry, PACTR201610001825403. FINDINGS: Between May 1, 2017, and March 31, 2019, 1340 participants were recruited: 457 (34·1%) assigned to the dedicated group, 438 (32·7%) assigned to the designated group, and 445 (33·2%) assigned to the treatment as usual group. 1174 (87·6%) participants completed the 12 month assessment. Compared with treatment as usual, the dedicated group (people with HIV adjusted mean difference -5·02 [95% CI -7·51 to -2·54], p<0·0001; people with diabetes -4·20 [-6·68 to -1·72], p<0·0001) and designated group (people with HIV -6·38 [-8·89 to -3·88], p<0·0001; people with diabetes -4·80 [-7·21 to -2·39], p<0·0001) showed greater improvement on depression scores at 12 months. By contrast, reductions in AUDIT scores were similar across study groups, with no intervention effects noted. INTERPRETATION: The dedicated and designated approaches to delivering CHW-led psychological interventions were equally effective for reducing depression, but enhancements are required to support alcohol reduction. This trial extends evidence for CHW-delivered psychological interventions, offering insights into how different delivery approaches affect patient outcomes. FUNDING: British Medical Research Council, Wellcome Trust, UK Department for International Development, the Economic and Social Research Council, and the Global Challenges Research Fund.

The prevalence and predictors of stigma amongst people living with HIV/AIDS in the Western Province.

The aim of the present study was determine the extent to which internalized and enacted stigma is experienced by people living with HIV/AIDS and to establish correlates of such experiences. A convenience sample of 400 HIV-positive participants was selected from three health clinics in the Cape Town area. Respondents' experiences of internalized and enacted stigma were investigated using the HIV/AIDS Stigma Instrument - PLWA (HASI-P). Overall, 28% of respondents endorsed more than one item addressing internalized stigma and 8% endorsed more than one item on any of the four subscales measuring enacted stigma. Male respondents (OR = 0.52, CI = 0.92-0.99), younger respondents (OR = 0.52, CI = 0.29-0.94), and those respondents who had been living with HIV longer were less likely to experience internalized stigma. More educated respondents (OR = 1.19, CI = 1.02-1.39) experienced more internalized stigma than those with less education No demographic characteristics predicted enacted stigma in this particular population. There are a number of possible reasons for low reports of HIV-related stigma, including having access to treatment and not disclosing HIV status.

Responding to COVID-19 threats to trial conduct: lessons learned from a feasibility trial of a psychological intervention for South African adolescents.

The COVID-19 pandemic has posed challenges to the conduct of clinical trials. Strategies for overcoming common challenges to non-COVID-19 trial continuation have been reported, but this literature is limited to pharmacological intervention trials from high-income settings. The purpose of this paper is to expand the literature to include a low- and middle-income country perspective. We describe the challenges posed by COVID-19 for a randomised feasibility trial of a psychological intervention for adolescents in Cape Town, South Africa, and lessons learned when implementing strategies to facilitate trial continuation in this context. We used a Plan-Do-Study-Act cycle method to explore whether our adaptations were having the desired effect on trial accrual and retention. We found that stakeholder engagement, trial coordination and team communication need to be intensified while testing these procedural changes. We learned that strategies found to be effective in high-income countries required significant adaptation to our resource-constrained setting. The detailed documentation of extraneous influences, procedural changes and trial process information was essential to guiding decisions about which adaptations to retain. This information will be used to examine the potential impact of these changes on study outcomes. We hope that these reflections will be helpful to other trialists from low- and middle-income countries grappling with how to minimise the impact of public health emergencies on their research. TRIAL REGISTRATION: The trial is registered with the Pan African Clinical Trials Registry (PACTR20200352214510). Registered 28 February 2020.   https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9795 .

Perspectives towards mental illness in people living with HIV/AIDS in South Africa.

Psychiatric disorders are more common in people living with HIV/AIDS (PLWHA) than in the general population and they exert a significant effect on many health-related outcomes. Low levels of mental health literacy and stigma may contribute to delayed treatment seeking and poorer outcomes. A convenience sample of 400 HIV-positive respondents were selected from three health clinics in Cape Town. Respondents' mental health literacy and attitudes towards psychiatric disorders were investigated. Psychiatric disorders were viewed as stress-related 70-91% of the time. Seeking help from a medical professional was often endorsed as an effective treatment option, while taking medication was rarely endorsed. Respondents held negative attitudes towards people with psychiatric disorders. In particular, people with substance abuse and PTSD were stigmatised more than those with depression and schizophrenia. The understanding of the psychobiological nature of psychiatric disorders and of existing effective treatments in PLWHA in South Africa is limited. Interventions designed to increase mental health literacy and reduce the stigma associated with psychiatric disorders may increase the likelihood of PLWHA seeking treatment should they suffer from these conditions.

Knowledge of and stigma associated with mental disorders in a South african community sample.

The aim of this study was to assess the awareness of, attitudes toward, and stigma associated with psychiatric disorders among South Africans. A convenience sample of 1081 members of the general public participated in the study. One of 10 vignettes portraying different psychiatric disorders with subtle or obvious symptoms was presented to each respondent. Schizophrenia was reported as being the most representative of a psychiatric disorder and post-traumatic stress disorder as the least representative. Psychosocial stress was reported more frequently than medical etiologies as a possible cause of mental disorders. Seeking help from a health professional in the form of psychotherapy was often endorsed as an effective treatment option, whereas taking medication was rarely endorsed. Respondents held more stigmatizing attitudes toward patients with substance abuse and schizophrenia, whereas post-traumatic stress disorder was stigmatized significantly less than the other conditions. Further effort is required to educate the public about the psychobiological underpinnings of psychiatric disorders and about the value of effective treatments.

"Moving Forward with Life": Acceptability of a Brief Alcohol Reduction Intervention for People Receiving Antiretroviral Therapy in South Africa.

BACKGROUND: In South Africa, interventions are needed to address the impact of hazardous drinking on antiretroviral therapy among people living with HIV (PLWH). Participant feedback about these interventions can identify ways to enhance their acceptability. We interviewed participants in a randomized controlled trial of a brief motivational interviewing and problem-solving therapy (MI-PST) intervention about their perceptions of this alcohol-reduction intervention. METHODS: The trial was conducted in HIV treatment clinics operating from six hospitals in the Tshwane region of South Africa. We conducted qualitative in-depth interviews with a random selection of participants. Twenty-four participants were interviewed after the final intervention session and 25 at the six-month follow up. RESULTS: Participants believed that it was acceptable to offer PLWH, an alcohol reduction intervention during HIV treatment. They described how the MI-PST intervention had helped them reduce their alcohol consumption. Intervention components providing information on the health benefits of reduced consumption and building problem-solving and coping skills were perceived as most beneficial. Despite these perceived benefits, participants suggested minor modifications to the dosage, content, and delivery of the intervention for greater acceptability and impact. CONCLUSIONS: Findings highlight the acceptability and usefulness of this MI-PST intervention for facilitating reductions in alcohol consumption among PLWH.

The internalized stigma experienced by members of a mental health advocacy group in South Africa.

BACKGROUND: Although there is a growing literature on internalized stigma from the developed world, very little research has been conducted in developing countries such as South Africa. Therefore, the purpose of this study was to describe the internalized stigma experienced by members of a mental health advocacy group in South Africa and relationships between self-stigma and other constructs, namely, empowerment, perceived devaluation and discrimination. METHODS: Self-administered questionnaires measuring respondents reported levels of internalized stigma, empowerment and perceived devaluation and discrimination were distributed to all the members of the South African Depression & Anxiety Group (SADAG) by post and via email. Of the 850 members invited to participate, 142 members of SADAG completed the questionnaire. Pearson correlations were computed and multiple regression analyses were carried out to analyse the data. RESULTS: The highest reports of stigma were for stigma resistance (mean = 2.9), alienation (mean = 2.47) and perceived discrimination (mean = 2.24). Low levels of stereotype endorsement (mean = 1.77) and social withdrawal (mean = 1.22) were reported. Although respondents often felt that the public held negative attitudes towards individuals suffering with a mental illness (perceived devaluation and discrimination scale (PDD), mean = 2.95), a majority of respondents reported high levels of empowerment (mean = 3.0) and self-efficacy (mean = 2.47). After controlling for socio-demographic factors, higher scores on the PDD were associated with social withdrawal and having experienced discrimination. CONCLUSION: Internalization of stigma, disempowerment and loss of self-esteem are not inevitable consequences for all individuals with a mental illness. Nevertheless, perceived stigma is significantly associated with social withdrawal and experienced discrimination.