Interpersonal psychotherapy delivered by nonspecialists for depression and posttraumatic stress disorder among Kenyan HIV-positive women affected by gender-based violence: Randomized controlled trial

Background HIV-positive women suffer a high burden of mental disorders due in part to gender-based violence (GBV). Comorbid depression and posttraumatic stress disorder (PTSD) are typical psychiatric consequences of GBV. Despite attention to the HIV-GBV syndemic, few HIV clinics offer formal mental healthcare. This problem is acute in sub-Saharan Africa, where the world's majority of HIV-positive women live and prevalence of GBV is high. Methods and findings We conducted a randomized controlled trial at an HIV clinic in Kisumu, Kenya. GBV-affected HIV-positive women with both major depressive disorder (MDD) and PTSD were randomized to 12 sessions of interpersonal psychotherapy (IPT) plus treatment as usual (TAU) or Wait List+TAU. Nonspecialists were trained to deliver IPT inside the clinic. After 3 months, participants were reassessed, and those assigned to Wait List+TAU were given IPT. The primary outcomes were diagnosis of MDD and PTSD (Mini International Neuropsychiatric Interview) at 3 months. Secondary outcomes included symptom measures of depression and PTSD, intimate partner violence (IPV), and disability. A total of 256 participants enrolled between May 2015 and July 2016. At baseline, the mean age of the women in this study was 37 years; 61% reported physical IPV in the past week; 91% reported 2 or more lifetime traumatic events and monthly income was 18USD. Multilevel mixed-effects logistic regression showed that participants randomized to IPT+TAU had lower odds of MDD (odds ratio [OR] 0.26, 95% CI [0.11 to 0.60], p = 0.002) and lower odds of PTSD (OR 0.35, [0.14 to 0.86], p = 0.02) than controls. IPT+TAU participants had lower odds of MDD-PTSD comorbidity than controls (OR 0.36, 95% CI [0.15 to 0.90], p = 0.03). Linear mixed models were used to assess secondary outcomes: IPT+TAU participants had reduced disability (-6.9 [-12.2, -1.5], p = 0.01), and nonsignificantly reduced work absenteeism (-3.35 [-6.83, 0.14], p = 0.06); partnered IPT+TAU participants had a reduction of IPV (-2.79 [-5.42, -0.16], p = 0.04). Gains were maintained across 6-month follow-up. Treatment group differences were observed only at month 3, the time point at which the groups differed in IPT status (before cross over). Study limitations included 35% attrition inclusive of follow-up assessments, generalizability to populations not in HIV care, and data not collected on TAU resources accessed. Conclusions IPT for MDD and PTSD delivered by nonspecialists in the context of HIV care yielded significant improvements in HIV-positive women's mental health, functioning, and GBV (IPV) exposure, compared to controls. Author summary Why was the study done? HIV-positive women in sub-Saharan Africa experience high levels of gender-based violence (GBV), leading to a very high prevalence of mental disorders, particularly depression and posttraumatic stress disorder (PTSD). Despite knowledge that evidence-based psychotherapy for depression and PTSD can be delivered by local nonspecialists in East Africa with high efficacy, little data exists on scalable treatment models for HIV-positive women affected by GBV in the region. What did the researchers do and find? We partnered with a large HIV clinic in western Kenya to conduct a randomized controlled trial of interpersonal psychotherapy (IPT) versus Wait List-treatment as usual (TAU). Participants were 256 women enrolled in HIV care and affected by GBV who met criteria for major depressive disorder (MDD) and PTSD (primary outcomes). We used a scalable intervention in which local nonspecialists (no prior mental health training required) were trained to deliver IPT inside an HIV clinic, working closely with HIV clinic staff and providers. At the conclusion of treatment, those who received IPT had significant reduction in MDD, PTSD, and combined MDD-PTSD compared to Wait List+TAU controls. Wait List+TAU participants experienced similar remission after they received IPT treatment and gains were maintained across follow-up. Secondary findings: Compared with controls, IPT participants had a greater reduction of disability, intimate partner violence, and nonsignificantly reduced work absenteeism. What do these findings mean? This study suggests that IPT can be delivered in a scalable manner, including administration by nonspecialists, housed within existing HIV clinics. Delivering IPT to HIV-positive women affected by GBV using clinic-integrated nonspecialists can achieve substantial remission of MDD and PTSD sustained over 6-month follow-up, with apparent reductions in disability and physical violence by intimate partners.

Automated summary

The study found that implementing interpersonal psychotherapy for HIV-positive women affected by gender-based violence in Kenya significantly improved mental health, functioning, and exposure to intimate partner violence, compared to controls. Delivery of IPT by nonspecialists within existing HIV clinics was shown to be scalable and effective in reducing depression, PTSD, disability, and violence.