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1.
Cogn Behav Pract ; 27(1): 84-92, 2020 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-32153343

RESUMEN

HIV is prevalent in Sub-Saharan Africa, and depression frequently co-occurs. Depression is one of the most important predictors of poor adherence to antiretroviral therapy (ART). Little has been done to develop integrated interventions that are feasible and appropriate for task-shifting to nonspecialists that seek to address both depression and barriers to ART adherence in Sub-Saharan Africa. This case series describes an integrated intervention for depression and ART adherence delivered by a lay adherence counselor and supervised by a local psychologist. The 6-session intervention was based on problem-solving therapy for depression and for barriers to adherence (PST-AD), with stepped care for those whose depression did not recover with PST-AD. Primary outcomes were acceptability and depression. Acceptability was measured by participant attendance to the 6 sessions. Three case studies illustrate the structured intervention, solutions identified to adherence barriers and to problems underlying low mood, and changes seen in the clients' psychological symptoms. Acceptability of the intervention was high and common mental disorder symptoms scores measured using the SRQ-8 decreased overall. An integrated intervention for depression and adherence to ART appeared feasible in this low-income setting. An RCT of the intervention versus an appropriate comparison condition is needed to evaluate clinical and cost-effectiveness.

2.
AIDS Behav ; 22(1): 86-101, 2018 01.
Artículo en Inglés | MEDLINE | ID: mdl-28063075

RESUMEN

Using a pilot trial design in an HIV care clinic in Zimbabwe, we randomised 32 adults with poor adherence to antiretroviral therapy and at least mild depression to either six sessions of Problem-Solving Therapy for adherence and depression (PST-AD) delivered by an adherence counsellor, or to Enhanced Usual Care (Control). Acceptability of PST-AD was high, as indicated by frequency of session attendance and through qualitative analyses of exit interviews. Fidelity was >80% for the first two sessions of PST-AD but fidelity to the adherence component of PST-AD dropped by session 4. Contamination occurred, in that seven patients in the control arm received one or two PST-AD sessions before follow-up assessment. Routine health records proved unreliable for measuring HIV viral load at follow-up. Barriers to measuring adherence electronically included device failure and participant perception of being helped by the research device. The study was not powered to detect clinical differences, however, promising change at 6-months follow-up was seen in electronic adherence, viral load suppression (PST-AD arm 9/12 suppressed; control arm 4/8 suppressed) and depression (Patient Health Questionnaire-4.7 points in PST-AD arm vs. control, adjusted p value = 0.01). Results inform and justify a future randomised controlled trial of task-shifted PST-AD.


Asunto(s)
Depresión/etiología , Depresión/terapia , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/psicología , Cumplimiento de la Medicación/psicología , Aceptación de la Atención de Salud/psicología , Solución de Problemas , Adulto , Terapia Cognitivo-Conductual , Estudios de Factibilidad , Femenino , Infecciones por VIH/complicaciones , Infecciones por VIH/virología , Humanos , Masculino , Persona de Mediana Edad , Admisión y Programación de Personal , Evaluación de Programas y Proyectos de Salud , Zimbabwe/epidemiología
3.
J Health Psychol ; 22(10): 1265-1276, 2017 09.
Artículo en Inglés | MEDLINE | ID: mdl-26893295

RESUMEN

Few evidence-based interventions to improve adherence to antiretroviral therapy have been adapted for use in Africa. We selected, culturally adapted and tested the feasibility of a cognitive-behavioural intervention for adherence and for delivery in a clinic setting in Harare, Zimbabwe. The feasibility of the intervention was evaluated using a mixed-methods assessment, including ratings of provider fidelity of intervention delivery, and qualitative assessments of feasibility using individual semi-structured interviews with counsellors (n=4) and patients (n=15). The intervention was feasible and acceptable when administered to 42 patients and resulted in improved self-reported adherence in a subset of 15 patients who were followed up after 6months.


Asunto(s)
Antirreumáticos/uso terapéutico , Terapia Cognitivo-Conductual/métodos , Asistencia Sanitaria Culturalmente Competente/métodos , Infecciones por VIH/tratamiento farmacológico , Cumplimiento de la Medicación/etnología , Evaluación de Procesos y Resultados en Atención de Salud , Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adulto Joven , Zimbabwe/etnología
4.
JAMA ; 316(24): 2618-2626, 2016 12 27.
Artículo en Inglés | MEDLINE | ID: mdl-28027368

RESUMEN

Importance: Depression and anxiety are common mental disorders globally but are rarely recognized or treated in low-income settings. Task-shifting of mental health care to lay health workers (LHWs) might decrease the treatment gap. Objective: To evaluate the effectiveness of a culturally adapted psychological intervention for common mental disorders delivered by LHWs in primary care. Design, Setting, and Participants: Cluster randomized clinical trial with 6 months' follow-up conducted from September 1, 2014, to May 25, 2015, in Harare, Zimbabwe. Twenty-four clinics were randomized 1:1 to the intervention or enhanced usual care (control). Participants were clinic attenders 18 years or older who screened positive for common mental disorders on the locally validated Shona Symptom Questionnaire (SSQ-14). Interventions: The Friendship Bench intervention comprised 6 sessions of individual problem-solving therapy delivered by trained, supervised LHWs plus an optional 6-session peer support program. The control group received standard care plus information, education, and support on common mental disorders. Main Outcomes and Measures: Primary outcome was common mental disorder measured at 6 months as a continuous variable via the SSQ-14 score, with a range of 0 (best) to 14 and a cutpoint of 9. The secondary outcome was depression symptoms measured as a binary variable via the 9-item Patient Health Questionnaire, with a range of 0 (best) to 27 and a cutpoint of 11. Outcomes were analyzed by modified intention-to-treat. Results: Among 573 randomized patients (286 in the intervention group and 287 in the control group), 495 (86.4%) were women, median age was 33 years (interquartile range, 27-41 years), 238 (41.7%) were human immunodeficiency virus positive, and 521 (90.9%) completed follow-up at 6 months. Intervention group participants had fewer symptoms than control group participants on the SSQ-14 (3.81; 95% CI, 3.28 to 4.34 vs 8.90; 95% CI, 8.33 to 9.47; adjusted mean difference, -4.86; 95% CI, -5.63 to -4.10; P < .001; adjusted risk ratio [ARR], 0.21; 95% CI, 0.15 to 0.29; P < .001). Intervention group participants also had lower risk of symptoms of depression (13.7% vs 49.9%; ARR, 0.28; 95% CI, 0.22 to 0.34; P < .001). Conclusions and Relevance: Among individuals screening positive for common mental disorders in Zimbabwe, LHW-administered, primary care-based problem-solving therapy with education and support compared with standard care plus education and support resulted in improved symptoms at 6 months. Scaled-up primary care integration of this intervention should be evaluated. Trial Registration: pactr.org Identifier: PACTR201410000876178.


Asunto(s)
Agentes Comunitarios de Salud , Asistencia Sanitaria Culturalmente Competente , Trastornos Mentales/terapia , Atención Primaria de Salud , Solución de Problemas , Psicoterapia , Adulto , Distribución por Edad , Ansiedad/epidemiología , Ansiedad/terapia , Agentes Comunitarios de Salud/educación , Depresión/epidemiología , Depresión/terapia , Femenino , Estudios de Seguimiento , Seropositividad para VIH/epidemiología , Humanos , Masculino , Trastornos Mentales/diagnóstico , Persona de Mediana Edad , Cooperación del Paciente/estadística & datos numéricos , Selección de Paciente , Grupo Paritario , Distribución por Sexo , Evaluación de Síntomas , Resultado del Tratamiento , Adulto Joven , Zimbabwe/epidemiología
5.
Trop Med Int Health ; 20(7): 903-13, 2015 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-25754063

RESUMEN

OBJECTIVE: To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings. METHODS: In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team. RESULTS: The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care. CONCLUSIONS: Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.


Asunto(s)
Fármacos Anti-VIH/uso terapéutico , Infecciones por VIH/complicaciones , Cumplimiento de la Medicación , Trastornos Mentales/complicaciones , Estrés Psicológico , Síndrome de Inmunodeficiencia Adquirida/complicaciones , Adulto , Cultura , Femenino , Infecciones por VIH/tratamiento farmacológico , Infecciones por VIH/psicología , Necesidades y Demandas de Servicios de Salud , Humanos , Entrevistas como Asunto , Masculino , Persona de Mediana Edad , Pobreza , Prevalencia , Estigma Social , Apoyo Social , Esposos , Estrés Psicológico/etiología , Pensamiento , Zimbabwe
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