Mental illness is a serious concern in the clinical management of HIV infection. In the United States, mood and anxiety disorders affect up to half of HIV+ patients. HIV+ individuals in resource-poor countries have similarly elevated rates of mental illnesses. Depression has been linked to a range of negative HIV-related behavioral and clinical health outcomes, including more sexual risk behaviors, worse antiretroviral therapy (ART) adherence, poor response to ART, faster immune system decline, and higher mortality. Approaches known as """"""""Measurement-Based Care"""""""" (MBC) integrated into primary care settings have effectively addressed comorbid depression in non-HIV patient populations. Multisite randomized clinical trials have demonstrated the efficacy of MBC models, which employ clinical coordinators with depression expertise to help physicians implement guideline-concordant, algorithm-driven antidepressant treatment. The development of effective, culturally appropriate mental health interventions for HIV patients is particularly time-critical in sub-Saharan Africa (SSA), home to nearly two-thirds of the estimated 33 million people infected with HIV. Combination ART is just starting to become widely available in the region. Successful ART treatment and the prevention of drug resistance hinge on strict medication adherence. As depression is one of the most consistent predictors of poor adherence and has been declared by expert panels to be an important concern in the management of HIV around the world, tested interventions to address mental health issues in African HIV clinical settings are sorely needed. In the present R34 application, we propose to assess the feasibility and acceptability of implementing a randomized controlled trial (RCT) of an MBC depression management program that is primarily staffed by nurses and integrated into HIV clinical care sites. Project activities will take place in the English-speaking region of Cameroon due to the long-standing collaborative relationship between the University of North Carolina-Chapel Hill Center for AIDS Research and the Center for the Study and Control of Communicable Diseases of the University of Yaound? in Yaound?, Cameroon.
Our specific aims are to (1) Establish the validity, reliability, and cultural appropriateness of a case identification protocol to identify patients with major depressive disorder (MDD) at a semi-urban HIV clinical care site in English-speaking Cameroon;(2) Adapt an MBC treatment intervention for patients with MDD to the context of HIV treatment in Cameroon, and train HIV providers and nurses in implementing the intervention;and (3) Evaluate the feasibility of recruiting and retaining patients from our partnering clinic and collecting and processing laboratory specimens. Should our intervention prove feasible and demonstrate evidence of potential effectiveness, we will compete for R01 funding. This subsequent funding would permit us to implement an RCT of the effect of this depression identification and treatment protocol on ART adherence, HIV clinical indicators, and mental health outcomes.
This project will adapt a proven depression treatment intervention so it can be implemented for HIV patients in Cameroon. We will validate a depression severity measure, adapt key elements of the intervention to the Cameroon context, train nurses and physicians to carry out the intervention, and examine preliminary outcomes in a pilot sample of 60 patients over 12 months.
