Doctoral Degrees (Psychiatry)

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Browsing Doctoral Degrees (Psychiatry) by Subject "Alcoholism -- Risk factors -- Zimbabwe"

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    An 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.