| dc.description.abstract | Background
Adolescents living with HIV in sub-Saharan Africa have a higher mental health burden, lower care engagement, and poor medication adherence. To improve treatment outcomes, support interventions that are tailored to the dynamic social and cognitive needs of adolescents as they pass through life-stages need to be developed/adapted, tested and promoted. Mindfulness and acceptance-based interventions are slowly gaining traction as appropriate for adolescents but have not been used in resource constrained settings with young people living with HIV.
Purpose
The aim of the study was to adapt a mindfulness and acceptance-based intervention for young people in Uganda who are living with HIV, with a focus on cultural saliency and contextual relevance and to evaluate the effectiveness of the adapted intervention in reducing symptoms of depression, anxiety, and internalized HIV stigma as well as improving adherence to antiretroviral therapy among adolescents recruited from two public health centres in Kampala, Uganda.
Methods
A sequential multi-methods design was used to achieve the study objectives; combining adaptation models, qualitative inquiries and a quantitative parallel group trial. The study was divided into two phases. Phase One encompassed cultural adaptation and qualitative inquiries while Phase Two involved the randomized trial.
In phase one, adaption was guided by two adaptation frameworks (the Formative Method for Adapting Psychotherapy and the Ecological Validity Model) which worked as blueprints that guided engagement of n=30 stakeholders to modify the intervention manual for cultural salience and contextual relevance, while exploratory qualitative approach guided by the Theoretical Framework of Acceptability was used to generate qualitative data among n=9 users and n=10 providers on retrospective and prospective acceptability of the adapted intervention. Qualitative data was abductively analysed and organized under a priori themes from the Theoretical Framework of Acceptability. Finally, the study tested the effectiveness of the adapted intervention on reducing symptoms of depression, anxiety and stigma and self-reported adherence to antiretroviral therapy among n=122 adolescents with HIV through an open label randomized trial (ClinicalTrials.gov: NCT05010317). Data was analyzed using mixed effects regression.
Results
Key adaptations to the intervention included simplifying the language of the training manual into plain English (British level A2 or basic level), adding local practices, integrating locally relevant slang and stories into therapy, introducing culturally relevant visuals and cards representing emotions, and adjusting therapy materials for use in resource-constrained settings. The acceptability assessment indicated that users perceived the intervention to be acceptable, with many stating that it helped them overcome fears, increased their self-acceptance, and gave them the confidence to make careful health-enhancing decisions. Providers also found the intervention to be acceptable and appropriate for use with adolescents, citing benefits such as; the intervention offering support beyond a focus on adherence to drugs, refocusing adolescents on aspects of their lives that matter most, and being easy to integrate into their work processes. They however expressed concern about the time the intervention requires and the possibility of increasing their workload.
Results from the trial showed that the intervention was associated with statistically significant reductions in symptoms of depression (β=-10.54, 95 %CI: -8.03 to -0.56; p <.001), anxiety (β=-7.310, 95 %CI: -11.869 to -2.751; p =.002) and stigma (β=-1.484, 95 %CI: -2.172 to -0.797; p =<0.001) over time, while no significant effect was observed on adherence to ART (β=.02, 95 %CI: -.27, .33; p =.85). Furthermore, being in school was a strong predictor of reductions in depression symptoms and anxiety over time while age and sex were not significant.
Conclusion
The adapted intervention was perceived to be acceptable by both providers and users, resulted in reduction in symptoms of depression, internalized stigma and anxiety but it had no impact on self-reported adherence to ART among adolescents with HIV in Uganda. It can be deduced from the study that adherence to ART remains a considerable challenge among AWH and may not be addressed by a single approach but rather a comprehensive strategy that incorporates various components of care | en_US |
