Can a Mental Health Intervention Improve Outcomes Among Youth With HIV?

Unaddressed mental health challenges among youth living with HIV complicate antiretroviral therapy (ART) adherence, leading to high mortality and lower rates of viral suppression among this population.

To tackle these challenges, investigators in the United States and Tanzania conducted a randomized pilot group treatment trial to evaluate a mental health intervention. The results were presented in a poster at the Annual Conference on Retroviruses and Opportunistic Infections (CROI 2020).

Dorothy Dow, MD, MSc-GH, a pediatric infectious diseases specialist with Duke Health, and presenting author on the study,

Contagion^®: What was the context for the undertaking of this study?

Dorothy Dow, MD, MSc-GH: I moved to Tanzania in 2011 to conduct my pediatric infectious diseases fellowship, which originally focused on prevention of maternal-to-child transmission of HIV. This research showed great strides in keeping new babies negative; however, my clinical experience in the adolescent HIV clinic painted a very different picture. The clinic was overburdened. Health care providers didn’t have time to really talk to patients. Adolescents would report taking their antiretrovirals but, in truth, they were not. We didn’t have the ability to check viral loads as standard-of-care at that time, but CD4s were dropping and patients were dying of opportunistic diseases.

In 2013, I received a small Duke Center for AIDS Research grant to evaluate the mental health challenges of adolescents living with HIV. As expected, the prevalence was quite high (between 25-45% from 2 clinical populations at Kilimanjaro Christian Medical Centre and Mawenzi Regional Referral hospital). In qualitative interviews, what was very striking was that essentially all participants (62 interviews), both young men and women, young adolescents and older youth, broke down in tears at some point when telling their story of when they found out they have HIV.

There were no mental health care professionals at KCMC, no psychologist nor psychiatrist, and the 2 social workers were overwhelmed managing all patients living with HIV at the hospital. We felt we could not uncover this significant mental health need yet do nothing about it. With the encouragement and support of my primary mentor, Coleen Cunningham, and US-based clinical psychologist, Karen O’Donnell, my co-investigator and Tanzanian pediatrician, Blandina Mmbaga, I received a Fogarty K01 in 2015 to design and test an intervention to address this need.

Together with the youth and young adult group leaders, we designed a group-based mental health and life skills intervention that the youth named “Sauti ya Vijana.” The intervention includes 10 group sessions (2 which are held jointly with caregivers), 2 individual sessions (1 on 1 with group leaders), and was designed to meet the needs we discovered in our formative research. Three sessions are dedicated to helping youth talk about hard memories and discuss the narrative of when they found out they have HIV individually with a group leader, with the group, and finally with their caregiver. A separate session (session 9) is totally dedicated to helping youth decide how and to whom to disclose their HIV status. Practicing the narrative and taking control of their thoughts through cognitive behavioral therapy helped youth begin to feel comfortable talking about their HIV status…at least in a safe, group setting.

The SYV pilot RCT is wrapping up (the sixth and final wave of youth will finish end of March) and the results look promising.

Contagion^®: What were the key findings of the poster presented at CROI 2020?

Dow: Young adult group leaders can effectively deliver the intervention with fidelity. The stress and worries that young people living with HIV named during the intervention sessions were numerous and fairly consistent across age and gender in the adolescent development period. Stigma and fitting in were major reasons that young people stop taking their medication. The intervention was acceptable and feasible to deliver in this setting (Moshi, Tanzania) and though not powered to show significant change, SYV revealed promising trends towards improved mental health, adherence, and virologic suppression in the intervention arm compared to standard of care.

Contagion^®: What are the larger clinical takeaways?

Dow: Despite knowing how to diagnose and treat HIV, young people continue to die at a rate far greater than other age groups. The unique adolescent developmental period demands that extra time be spent with these patients in order to understand their complex psychosocial dynamics, emerging mental health challenges, and sexual reproductive health needs. With the lack of adolescent friendly services and health care workers to meet this need, interventions like Sauti ya Vijana must be scaled in order to reduce mortality and prevent new HIV transmission to others.

Contagion^®: Are there plans for future research on this topic?

Dow: Of course. We are awaiting feedback for a grant proposal to scale the SYV intervention in a hybrid type-1 effectiveness-implementation randomized controlled trial across Tanzania. Additionally, I am co-chair of the IMPAACT 2016 protocol, which is evaluating a very different intervention to address mental health needs in 4 countries in southern Africa.

The poster, “Promising results from a pilot RCT mental health intervention for HIV-infected youth,” was virtually presented at CROI 2020 on Monday, March 9, 2020.