Group therapy improves mental health outcomes for people living with HIV in rural Uganda
Lay health worker-led psychotherapy is an effective and cost-effective strategy to improve mental health outcomes among people living with HIV in low-resourced settings.
Lay health workers can successfully deliver psychological treatment to people living with both HIV and mild to moderate depression, reveals a new study from rural Uganda.
Published last month in the Lancet Global Health, the study is the first large-scale study to look at the effectiveness of task-shifting depression therapy to lay health workers in sub-Saharan Africa.
Interventions that address mental health among people living with HIV are well recognised. This is driven by evidence that depression, post-traumatic stress disorder and hazardous drinking can stop people accessing their antiretroviral treatment (ART) and living well with HIV.
A total of 30 health centres in the rural, post-conflict districts of Gulu, Kitgum and Pader in northern Uganda, participated in the trial. Health centres were split up into two groups – one group was given group therapy sessions, while the other group received group sessions on HIV education.
The therapy sessions were designed using insights from local people with HIV and depression. In them, participants learnt positive coping skills, including ways to manage depressive thoughts and excessive worries. Problem-solving skills, skills for coping with stigma and discrimination, and income-generating skills were also taught.
Participants attending the HIV education sessions were taught about how HIV progresses in the body, HIV transmission and prevention, mother-to-child transmission, and basic facts about ART.
1,140 adults attended either a therapy or an HIV education group. All participants were on ART and had mild to moderate-major depression but were not on antidepressants.
Both the group therapy and HIV education sessions were led by local health workers who had received training on running the sessions but were not qualified psychologists.
Attendance was relatively high, with 78% of group-therapy participants and 89% of HIV-education participants attending every session of the 8-week course. All participants, whether they attended every week or not, were assessed six months after the sessions ended, then again after 12 months.
At six months, 2 people (<1%) had major depression in the group therapy arm which increased to 3 after one year. Among those who received HIV education only, major depression was reported in 160 (28%) people at six months, which increased to 225 (40%) after one year.
In addition, Substantially fewer group-therapy participants reported post-traumatic stress, suicide risk, and hazardous alcohol use than HIV-education participants, and were also more likely to adhere to ART. Although those attending the HIV education sessions did display improvements in each of these indicators, progress did not sustain as well over time. Viral load suppression was found to be similar between the two groups.
Both men and women responded positively to the group therapy sessions, but the greatest response was observed among men. Given the low participation of men in health services in many sub-Saharan African countries, this finding suggests that integrating group therapy into existing HIV care might encourage more men to engage in services.
The intervention was found to be very cost-effective for Uganda, with an incremental cost-effectiveness of US$13 per disability-adjusted life-year averted.
The findings suggest that lay health workers delivering group therapy within routine primary HIV care have the potential to improve the mental health, and potentially ART outcomes, of people living with HIV and depression. This is particularly important for people living with HIV who are facing difficult circumstances, such as refugees or those living in conflict or post-conflict areas; where depression and other mental health problems are common.