Association between Stigma and Emotional and Behavioral Difficulties (EBDs) and Impact of Two Evidence-Based Interventions on Ebds Among Adolescents Living with HIV in Southern Uganda: The Suubi4Stigma Pilot Study

Background: Adolescents living with HIV (ALHIV) have been found to have high prevalence of behavioral and emotional difficulties. Emotional and behavioral difficulties (EBDs) among ALHIV are important public health problems that can persist into adulthood and can impede progress toward HIV elimination. Despite the important public health implications of EBDs for HIV elimination and their high prevalence among ALHIV, there are currently limited studies assessing their association with stigma and whether these outcomes can be improved through interventions. Therefore, the purpose of this study is to assess whether internalized stigma is associated with child emotional and behavioral difficulties and if the Suubi4Stigma intervention, designed to address HIV related stigma has any impact on these outcomes among ALHIV in Southwestern Uganda.

Methods: We utilized data from a two-year pilot study called Suubi4Stigma. This was a three-arm cluster randomized controlled trial (RCT) to evaluate the feasibility, acceptability and preliminary impact of two evidence informed interventions of group cognitive behavioral therapy (G-CBT) versus family strengthening (FS) intervention delivered through multiple family groups (MFG) compared to usual care. Nine clinics were randomized to one of three study arms: 1) Usual Care; 2) G-CBT + Usual care; and 3) MFG + Usual care. This study utilized data collected during all three waves of the 2-year study (2020 – 2022). We utilized multilevel linear regression models to determine the association between HIV relate stigma and EBDs. We used we used mixed effects models while employing the xtmixed command in Stata to assess the effect of the intervention (G-CBT and MFG-FS) on child EBDs.

Results: We did not find a significant association between HIV stigma and child EBDs. However, we observed that, in the G-CBT group, the child emotional and behavioral difficulties had reduced at three months [contrast=-7.59 (CI: -8.20 – -6.99), <0.001] and 6-months [contrast=-8.11 (CI: -12.64 – -3.57), <0.001] compared to baseline. In the MFG-FS group, the emotional and behavioral difficulties increased at 6 months compared to 3 months [contrast=4.91 (CI: 1.08 – 8.01), <0.001].

Conclusions: While no association between stigma and child EBDs was observed in this study sample, participants in the G-CBT had appreciable and sustained improvements in their EBDs post-intervention. Additionally, the family-strengthening intervention delivered through MFG did not have any apparent positive impact on child EBDs. Future studies should investigate combination of MFG and G-CBT in addition to the individual components of the intervention.