In response to the NIH/PEPFAR RFA for implementation science and impact evaluation, this application addresses these priority areas: integration of HIV primary care and a common co-morbidity (depression), and examining depression treatment as a means to promote HIV care adherence, and prevention of transmission. Building on our research that highlights the role of depression in thwarting efforts to combat HIV disease on several public health fronts, and the relative absence of depression treatment in HIV care programs throughout sub-Saharan Africa (SSA) despite our observed efficacy of antidepressants with persons living with HIV/AIDS (PLHA), the proposed project will evaluate a task-shifting approach to building the capacity for sustainable depression treatment. Lack of trained mental health specialists is a major barrier to provision of treatment, yet task-shifting approaches to overcoming human resource limitations have been successful for ART scale-up in SSA, as well as provision of depression treatment in collaborative care models with non-HIV patients;however, the proposed study may be the first study of such a model with PLHA, and in SSA. We will test an algorithm-based, nurse-driven model for managing antidepressant treatment that includes (1) case identification facilitated by routine depression screening at each clinic visit for all patients, (2) training nurses to assist primary care provides in implementing antidepressant treatment by performing the initial evaluation, monitoring symptoms and side effects, and making algorithm-based dose recommendations, and (3) layers of supervision and monitoring by psychiatric specialists to ensure safety and quality of care. Using a cluster- randomization design, the task-shifting model will be implemented at six clinics, while six other clinics will use the standard physician-driven model. At each site, a random sample of 150 medically stable patients who screen positive for depression will be followed for 12 months to assess whether the two models of treatment differ on the quality of care indicators of antidepressant treatment uptake and change in depression. We will also assess whether change in depression is associated with key economic and public health outcomes including ability to work and provide for one's family, consistent condom use, and HIV care adherence. Time-and-motion assessments will be done with new samples of 100 randomly selected patients at each site during two week periods before, and one and two years after, initiation of the treatment models to assess impact on clinic efficiency and patient flow. If we demonstrate that this task-shifting approach to depression treatment is feasible, effective and well incorporated into clinic systems, it will establish a model that addresses the human resource challenges to building the capacity for sustainable depression treatment.

Public Health Relevance

This study is important to public health as its findings could demonstrate that the task-shifting approach to depression treatment is feasible, effective and well incorporated into clinic systems-hence, establishing a model that addresses the human resource challenges to building the capacity for sustainable depression treatment. The findings will also reveal the role of depression and its treatment in unleashing the public benefits of HIV treatment, and thus inform public policy on the importance of integrating depression treatment into HIV care programs.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Special Emphasis Panel (ZAI1-BP-A (J2))
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Gordon, Christopher M
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Rand Corporation
Santa Monica
United States
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Wagner, Glenn J; Ghosh-Dastidar, Bonnie; Robinson, Eric et al. (2017) Effects of Depression Alleviation on Work Productivity and Income Among HIV Patients in Uganda. Int J Behav Med 24:628-633
Wagner, Glenn J; Ngo, Victoria; Goutam, Prodyumna et al. (2016) A Structured Protocol Model of Depression Care versus Clinical Acumen: A Cluster Randomized Trial of the Effects on Depression Screening, Diagnostic Evaluation, and Treatment Uptake in Ugandan HIV Clinics. PLoS One 11:e0153132
Odokonyero, Raymond; Wagner, Glenn; Ngo, Victoria et al. (2015) Giving ""Sadness"" a Name: The Need for Integrating Depression Treatment into HIV Care in Uganda. J Int Assoc Provid AIDS Care 14:108-11