Browsing by Author "Madhombiro, Munyaradzi"
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- ItemAn adapted intervention for problematic alcohol use in people living with AIDS and its impact on alcohol use, general functional ability, quality of life and adherence to HAART : a cluster randomized control trial at Opportunistic Infections Clinics in Zimbabwe(Stellenbosch : Stellenbosch University, 2018-12) Madhombiro, Munyaradzi; Seedat, Soraya; Rusakaniko, Simba; Stellenbosch University. Faculty of Medicine and Health Sciences. Dept. of Psychiatry.ENGLISH SUMMARY : With the advent of antiretroviral therapy, the HIV pandemic has become a chronic illness requiring lifelong treatment. The 90-90-90 strategy, adopted by UNAIDS, aims for (i) 90% of HIV infected persons knowing their status, (ii) 90% on antiretroviral therapy; and (iii) 90% achieving viral suppression. The goal is to reach these aims by 2020. Alcohol use affects the attainment of the 90-90-90 goals. Research shows that people living with HIV (PLWH) drink twice as much as their HIV negative counterparts. Alcohol use disorders (AUD) in PLWH are associated with poor adherence to ART. Recommendations have been made to include interventions for AUDs in HIV prevention and treatment strategies. Brief interventions are recommended for hazardous alcohol use; however, for alcohol dependence a stepped care model incorporating behavioural/psychological treatments and pharmacological interventions may be required. Pharmacological treatments may lead to a higher pill burden and psychological interventions are, therefore, the treatment of choice. Psychological interventions have traditionally been delivered by a highly skilled workforce. However, in low and medium income countries (LMIC) where the HIV prevalence is high, there is a shortage of a skilled workforce. Task sharing has been recommended as a way of scaling up the delivery of services. The aim of this study was to adapt an evidence-based intervention for HIV and AUDs in Zimbabwe and to assess its effectiveness in a cluster randomized controlled trial (RCT). To achieve this, we first conducted a systematic review of the evidence for the effectiveness of psychological interventions. Second, a qualitative study was done to understand knowledge and perceptions of AUDs among PLWH and potential barriers and facilitators of interventions for AUDs. Third, we conducted a pilot and feasibility study in preparation for the RCT. The systematic review found limited evidence for the effectiveness of psychological interventions for AUDs, particularly on the frequency of drinking. Motivational interviewing (MI) alone and in combination with mobile technology, and cognitive behavioural therapy (CBT) were found to be effective. Additionally, MI was effective in reducing risky sexual behaviour, adherence to ART, other substance use disorders, viral load reduction, and increase in CD4 count. The qualitative study found that PLWH had adequate knowledge of the direct and indirect effects of alcohol use on HIV transmission and adherence to treatment, and were concerned about the stigma faced by PLWH who have and AUDs. Furthermore, participants were concerned about the stigma faced by PLWH who have AUDs. They called for stigma reduction strategies to be implemented and were receptive of the idea of interventions for AUDs. Following a pilot study which indicated that an intervention for AUDs was feasible, a cluster RCT was carried out at 16 HIV care clinics. The adapted intervention included motivational interviewing blended with cognitive behavioural therapy (MI/CBT). The comparator intervention was the alcohol use section of the World Health Organisation (WHO) mental health Gap Action Program Intervention Guide (mh GAP IG). The MI/CBT and mh GAP IG interventions were delivered by registered general nurses (RGN) embedded in HIV care clinics. The primary outcome was a reduction in alcohol use as measured by the Alcohol Use Disorders Identification Test (AUDIT) score. Secondary outcome measures included: (i) HIV disease parameters, as measured by the viral load and CD4 count; (ii) functionality, as assessed by the WHO Disability Assessment Schedule (WHODAS 2.0); and (iii) quality of life, as measured by the WHO Quality of Life HIV (WHOQOL HIV). The cluster RCT demonstrated that RGNs can be trained to deliver an MI/CBT intervention for AUDs in PLWH. Additionally, the MI/CBT intervention significantly reduced alcohol consumption in PLWH. While the reduction in alcohol consumption was maintained in the MI/CBT arm at 6 months, this effect was only maintained in the mh GAP IG arm up to 3 months. Additional improvements were seen in HIV treatment outcomes (especially viral load), functionality, and quality of life. Finally, it was feasible to deliver an MI/CBT intervention using a task sharing model. In terms of implementation, this can be done with a modest increase in staffing. Given the negative role AUDs play in the HIV treatment cascade, reduction in alcohol use can help in achieving the UNAIDS’ 90-90-90 goals. Further, effectiveness trials are needed in LMIC with a high prevalence of HIV. When conducting these trials, attention should be paid to patient experiences, such as the ‘double’ stigma of HIV and AUDs.
- ItemA cluster randomised controlled trial protocol of an adapted intervention for alcohol use disorders in people living with HIV and AIDS : impact on alcohol use, general functional ability, quality of life and adherence to HAART(BioMed Central, 2017-01-28) Madhombiro, Munyaradzi; Dube-Marimbe, Bazondlile; Dube, Michelle; Chibanda, Dixon; Zunza, Moleen; Rusakaniko, Simbarashe; Stewart, David; Seedat, SorayaENGLISH SUMMARY : Background: Interventions for alcohol use disorders (AUDs) in HIV infected individuals have been primarily targeted at HIV risk reduction and improved antiretroviral treatment adherence. However, reduction in alcohol use is an important goal. Alcohol use affects other key factors that may influence treatment course and outcome. In this study the authors aim to administer an adapted intervention for AUDs to reduce alcohol use in people living with HIV/AIDS (PLWHA). Methods: This study is a cluster randomised controlled trial at 16 HIV care clinics. A motivational interviewing and cognitive behavioural therapy based intervention for AUDs, developed through adaptation and piloted in Zimbabwe, will be administered to PLWHA with AUDs recruited at HIV clinics. The intervention will be administered over 16 sessions at 8 HIV clinics. This intervention will be compared with an equal attention control in the form of the World Health Organization Mental Health Gap Action Programme (WHO mhGAP) guide, adapted for the Zimbabwean context. General function, quality of life, and adherence to highly active antiretroviral treatment (HAART) will be secondary outcomes. Booster sessions will be administered to both groups at 3 and 6 months respectively. The primary outcome measure will be the Alcohol Use Disorder Identification Test (AUDIT) score. The World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0), World Health Organisation Quality of Life (WHOQoL) HIV, viral load, and CD4 counts will be secondary outcome measures. Outcome assessments will be administered at baseline, 3, 6, and 12 months. Moderating factors such as perceived social support, how people cope with difficult situations and post-traumatic exposure and experience will be assessed at baseline. Trained research assistants will recruit participants. The outcome assessors who will be trained in administering the outcome and moderating tools will be blinded to the treatment arms allocated to the participants. However, the principal investigator, participants and intervention staff will be unblinded. Data will be analysed using STATA Version 14. Primary and secondary outcomes will be measured at four time points that is; at baseline, 3, 6, and 12 months respectively. All participants will be included in the analysis of primary and secondary outcome measures. The mean AUDIT scores will be compared between groups using student t-tests. Multilevel logistic regression analysis will be performed for binominal variables and multilevel linear regression for continuous variables. Descriptive statistics will be computed for baseline and follow-up assessments. Discussion: The study will be the first to address problematic alcohol use in PLWHA in Zimbabwe. It seeks to use local resources in delivering a modified, brief, evidence-based, and culturally contextualised intervention. The study results will determine the effectiveness of adapting psychological interventions for AUDs in HIV infected adults using a task-sharing framework.
- ItemIntervention for alcohol use disorders at an HIV care clinic in Harare : a pilot and feasibility study(BMC (part of Springer Nature), 2019) Madhombiro, Munyaradzi; Dube, Bazondlile; Dube, Michelle; Zunza, Moleen; Chibanda, Dixon; Rusakaniko, Simbarashe; Seedat, Soraya, 1966-Background: Alcohol use in HIV infected patients is associated with risky sexual behaviour, poor adherence to Highly Active Antiretroviral Therapy, treatment failure and increased physiologic harm. The objectives of the study were to pilot the outcome assessments to be used in the trial proper, assess the feasibility of delivery of a brief MI/CBT intervention compared to an WHO mhGAP intervention for problematic alcohol use in PLWH in Zimbabwe, and pilot the effectiveness (on alcohol use, functionality and CD4 count) of these interventions at 3 months in a randomised controlled trial design. Methods: An intervention for HIV infected patients with problematic alcohol use, developed through adaptation of existing evidence based psychological treatments, was assessed for its feasibility at a tertiary HIV care clinic in Zimbabwe. Registered general nurses, using a manualised protocol, delivered the intervention. Forty patients were recruited and randomised to receive either an MI/CBT intervention or the WHO mhGAP Intervention Guide for AUDs (n = 20 patients per group). Results: Out of 40 participants enrolled, 31 were successfully followed up for 3 months with a loss to follow-up rate of 23%. There was a statistically significant decrease in AUDIT score over time in both groups (p < 0.001), however no statistically significant group difference with a mean difference of 0.80, standard error of 2.07 and p = 0.70. For the CD4 count, the median and interquartile ranges at baseline for MI/CBT and WHO mhGAP IG groups were 218 (274) and 484 (211.50), respectively. At follow-up, median and interquartile ranges for the CD4 count for MI/CBT and WHO mhGAP IG groups were 390 (280) and 567 (378), respectively, indicative of improvement in immunological parameters in both arms. Conclusion: The findings from this pilot study suggests that a brief MI/CBT delivered by Registered General Nurses for problematic alcohol use is feasible in this population but will require the implementation of additional measures to improve retention. However, mechanisms to improve retention need special attention.
- ItemPerceptions of alcohol use in the context of HIV treatment : a qualitative study(Dove Medical Press, 2018) Madhombiro, Munyaradzi; Marimbe-Dube, Bazondlile; Dube, Michelle; Kaiyo-Utete, Malinda; Paradzai, Angeline; Chibanda, Dixon; Rusakaniko, Simbarashe; Van Der Watt, A. S. J.; Seedat, SorayaBackground: Alcohol use is associated with poor HIV treatment outcomes. This study aimed to understand patients’ perceptions of the impact of alcohol use in the context of HIV care. Methods: The study design was a descriptive qualitative study of HIV positive individuals receiving antiretroviral treatment. The study involved four focus group discussions with male and female participants at a tertiary center, city clinic, and rural church. We employed convenience sampling and invited patients coming for their routine visits and medication refills to participate. Results: Participants had an awareness of both the direct and indirect effects of alcohol use. The direct effects related to the incompatibility of HIV medication and alcohol. The indirect effects related to the negative impact of alcohol on treatment adherence. Participants proffered reasons why HIV infected individuals on HIV treatment drink and felt that patients had to make a deliberate choice to stop drinking. Participants displayed some knowledge of interventions for drinking cessation and highlighted the use of pharmacological interventions to stop drinking. Participants indicated that they preferred HIV counselors to provide counseling services in view of the existing relationships that patients had with counselors. Conclusion: People living with HIV have adequate knowledge of the effects of alcohol use in the context of HIV treatment. Stigma and the time taken to engage in an alcohol use intervention appeared to be the main impediments to uptake. The current model of HIV treatment, based on trust with the HIV care team, and maintenance of this trust, could bolster the uptake of an intervention. Involvement of HIV patients in their treatment is necessary to improve treatment outcomes in the context of alcohol use.
- ItemPsychological interventions for alcohol use disorders in people living with HIV/AIDS : a systematic review(BMC (part of Springer Nature), 2019-10-28) Madhombiro, Munyaradzi; Musekiwa, Alfred; January, James; Chingono, Alfred; Abas, Melanie; Seedat, SorayaBackground: Alcohol use disorders (AUDs) in people living with HIV/AIDS (PLWH) are a significant impediment to achieving virological control. HIV non-suppression in PLWH with AUDs is mainly attributable to sub-optimal antiretroviral therapy adherence. Sub-optimal adherence makes control of the epidemic elusive, considering that effective antiretroviral treatment and viral suppression are the two key pillars in reducing new infections. Psychological interventions have been proposed as effective treatments for the management of AUDs in PLWH. Evidence for their effectiveness has been inconsistent, with two reviews (2010 and 2013) concluding a lack of effectiveness. However, a 2017 review that examined multiple HIV prevention and treatment outcomes suggested that behavioural interventions were effective in reducing alcohol use. Since then, several studies have been published necessitating a re-examination of this evidence. This review provides an updated synthesis of the effectiveness of psychological interventions for AUDs in PLWH. Methods: A search was conducted in the following databases: PubMed, Cochrane Central Register of Trials (CENTRAL), MEDLINE (Ovid), EMBASE, PsychInfo (Ovid) and Clinical trials.gov (clinicaltrials.gov) for eligible studies until August 2018 for psychotherapy and psychosocial interventions for PLWH with AUDs. Two reviewers independently screened titles, abstracts and full texts to select studies that met the inclusion criteria. Two reviewers independently performed data extraction with any differences resolved through discussion. Risk of bias was assessed by two independent reviewers using the Cochrane risk of bias tool, and the concordance between the first and second reviewers was 0.63 and between the first and third reviewers 0.71. Inclusion criteria were randomised controlled trials using psychological interventions in people aged 16 and above, with comparisons being usual care, enhanced usual care, other active treatments or waitlist controls. Results: A total of 21 studies (6954 participants) were included in this review. Studies had diverse populations including men alone, men and women and men who had sex with men (MSM). Use of motivational interviewing alone or blended with cognitive behavioural therapy (CBT) and technology/computer-assisted platforms were common as individual-level interventions, while a few studies investigated group motivational interviewing or CBT. Alcohol use outcomes were all self-report and included assessment of the quantity and the frequency of alcohol use. Measured secondary outcomes included viral load, CD4 count or other self-reported outcomes. There was a lack of evidence for significant intervention effects in the included studies. Isolated effects of motivational interviewing, cognitive behavioural therapy and group therapy were noted. However for some of the studies that found significant effects, the effect sizes were small and not sustained over time. Owing to the variation in outcome measures employed across studies, no meta-analysis could be carried out. Conclusion: This systematic review did not reveal large or sustained intervention effects of psychological interventions for either primary alcohol use or secondary HIV-related outcomes. Due to the methodological heterogeneity, we were unable to undertake a meta-analysis. Effectiveness trials of psychological interventions for AUDs in PLWH that include disaggregation of data by level of alcohol consumption, gender and age are needed. There is a need to standardise alcohol use outcome measures across studies and include objective biomarkers that provide a more accurate measure of alcohol consumption and are relatively free from social desirability bias.