Like most of sub-Saharan Africa, Rwandan youth are the epicenter of the AIDS epidemic, accounting for 40% of new infections. Antiretroviral (ART) adherence is a global health priority, but Rwandan youth are more than twice as likely to be on second line therapy as adults, and with a median population age of 18.7 years old, adherence is essential for Rwanda's future. Resources to provide youth-centered medical and psychosocial care are limited in Rwanda, and young people with HIV face many obstacles to adherence, namely the long-term consequences of genocide, depression, and gender-based violence, as well as logistical issues, negative attitudes, and insufficient parent/caregiver support. Preliminary data underscore the utility of culturally-adapted, trauma-informed cognitive behavioral therapy (TI-CBT) in reducing depression and traumatic distress among youth and adults in Rwanda. This project proposes a 2-arm RCT to test and compare the efficacy of adherence-enhanced TI-CBT (i.e., TI-CBTe) to usual care in increasing ART adherence among 350 Rwandan 14 - 21 year olds from the two clinics caring for the largest number of youth with HIV in Rwanda. Based on the Indigenous Leader Outreach Model, we will train 20 HIV+ indigenous youth leaders who are >95% ART adherent (IYL) and supervising psychologists to deliver the intervention. Youth, caregivers, and IYL will complete baseline, 6-, and 12-month follow-up assessments to assess effects on adherence and important mediators (trauma, depression, gender-based violence). We will use an intent-to-treat analysis and a combination of regression techniques and other inferential statistical tests for contrasting means and proportions. We will analyze treatment outcomes using logistic and linear multiple regression models examining effects at 6- and 12- months separately, as well as a combined model with random effects for repeated measurements across time. This proposal answers a compelling need for innovative programs to increase ART adherence among HIV+ youth. If effective, the study will build Rwanda's capacity to provide much needed services;and, involvement by the Rwanda Biomedical Center will ensure wide dissemination.
Like most of sub-Saharan Africa, youth are the epicenter of the AIDS epidemic in Rwanda, accounting for 40% of new infections. By 2010, general HIV prevalence in Rwanda was 3%, with 150,000 Rwandans living with HIV/AIDS. ART adherence is a global health priority following evidence from the HPTN 052, and >80% of Rwandan youth and adults are receiving antiretroviral therapy (ART). If taken as prescribed, ART can improve life expectancy, reduce co-morbidities, and enhance quality of life, whereas non-adherence has long-term consequences, including the emergence of virus resistant strains, limited future treatment options, and continued new transmissions. Studies of adherence among adolescents are discouraging as youth are significantly less adherent, achieve less viral suppression, and have larger viral rebound than adults. Rwandan youth also fare worse than adults;14-21 year olds are more than twice as likely to be on second line therapy (Rwandan national data). With a median population age of 18.7 years, adherence is essential for Rwanda's long-term health and productivity, yet few, if any, evidenced-based interventions exist for sub Saharan HIV+ youth. The long-term goal of this study is to increase ART adherence among HIV+ Rwandan youth by addressing their specific barriers - depression, trauma, and gender-based violence.