Preliminary Impact of Group-Based Interventions on Stigma, Mental Health and Treatment Adherence Among Adolescents Living with HIV in Uganda

Background and Purpose: Globally, an estimated 1.7 million children <15 years are living with HIV, with the majority living in Sub-Saharan Africa (SSA). Stigma is a major barrier to all aspects of the HIV care continuum. Studies have documented the adverse impact of HIV stigma on a range of cognitive, affective, and mental health outcomes among people living with HIV, including post-traumatic stress disorder (PTSD), depression, anxiety, and suicidal ideation, feelings of rejection, loneliness, social isolation, and low quality of life. While significant efforts have been made in developing and implementing HIV stigma reduction interventions in different settings, adolescents living with HIV (ALHIV) in SSA are significantly underrepresented. A recent systematic review of health-related needs reported by ALHIV receiving antiretroviral therapy (ART) in SSA identified stigma reduction as their primary health-related need –pointing to the need for data-driven research to address stigma among ALHIV as they transition into young adulthood. This study examined the preliminary impact of two evidence and theory-informed interventions: a group-based cognitive behavioral therapy (G-CBT) and a family strengthening intervention delivered via multiple family group (MFG-FS) to address HIV stigma and improve the mental health functioning of ALHIV (10-14 years) in Uganda.

Methods: We analyzed data from a two-year (2020-2022) pilot randomized clinical trial for ALHIV and their caregivers in Uganda. (N=89 child-caregiver dyads). Participants were recruited from 9 health clinics in the southern region. Inclusion criteria for adolescents included: 1) living with HIV and aware of their status; 2) between 10-14 years; 3) enrolled on ART in participating clinics; and 4) living within a family, including the extended family. Participants were randomized at the clinic level to three study conditions (n=3 clinics per condition): Usual care, G-CBT or MFG-FS. The interventions were provided for 3 months. Data were collected at baseline, 3 and 6-months post intervention initiation. We fitted separate three-level mixed-effects linear regression models to test the effect of the interventions on adolescents’ reported HIV stigma and shame; mental health functioning (depressive symptoms, hopelessness, PTSD symptoms, self-concept); and adherence to ART medication.

Results: The average age was 12 years, 62.9% were female, and 44.9% were orphans. Over time, participating in the interventions was associated with reduced depressive symptoms (x²(2) = 7.68, p=0.022). Across groups, we observed a significant decline in internalized stigma (c²(2) = 7.28, p=0.026), anticipated stigma (x²(2) = 9.47, p=0.009), shame (x²(2) = 120.86, p<0.001), depressive symptoms (x²(2) = 21.26, p<0.001), hopelessness (x²(2) = 19.05, p<0.001), PTSD (x²(2) = 19.26, p<0.001) and improvements in self-concept (x²(2) = 6.27, p=0.043). There were statistically significant group-by-time interaction effects for self-reported adherence (x²(4) =19.82, p<0.001), but not group or time effects.

Conclusions and Implications: ALHIV in SSA are underrepresented in stigma reduction interventions. Outcome trends from this pilot study contribute to our understanding of the potential of group-based intervention to address stigma and improve the mental health functioning of ALHIV. Findings provide compelling evidence to support testing the efficacy of these group-based interventions in a larger trial.