Effect of cognitive behavioural therapy on clinical depression, art adherence and HIV stigma among HIV-infected outpatients in Uasin-gishu County, Kenya

Abstract

Recent statistics indicate that HIV infection prevalence in Kenya is at 5.6 percent. Of note, HIV infection is commonly known for its tendency to present with comorbid conditions including neuropsychiatric disorders. Within this spectrum, depression, which is a mood disorder, is the most common neuropsychiatric disorder among persons living with HIV (PLHIV) occurring at rates 2 to 3 times higher than in HIV-negative persons. Depression contributes significantly to poor health outcomes among HIV-infected individuals by accelerating HIV progression. Evidently, depression has been associated with HIV-related stigma and non-adherence to Antiretroviral Therapy (ART) among PLHIV. However, proper recognition, timely diagnosis and treatment of depression among HIV-infected outpatients in Kenya remain low key. Most importantly, there is substantial evidence to support the use of psychotherapy and in particular Cognitive Behavioural Therapy (CBT) in the management of depression among PLHIV across diverse settings. The purpose of this study was to investigate the effect of CBT on depression, ART adherence and HIV stigma among HIV-infected outpatients in Turbo-Uasin Gishu County, Kenya. An experimental pretest/posttest control group design was adopted in this study, with CBT as the intervention in the experimental condition. The population of this study was 3000 HIV-infected adults attending Turbo Sub-County Hospital. A systematic random sampling was used to obtain an original sample size of 393 which was further subjected to eligibility criteria yielding 53 participants among whom 45 successfully completed the study against the desired powered sample size of 44. All participants were randomly assigned to either treatment or control conditions of the study in the ratio of 1:1. Patients randomised into the control group did not receive any form of psychotherapy during the active phase of the study period. Study variable measures were administered to participants both at baseline (one week before the intervention) and at month-2 post intervention assessment points. Data were collected using a set of instruments (PHQ-9 scale for depression; Patient Adherence Record for ART adherence; and HIV/AIDS-Related Stigma Scale for HIV stigma) and keyed into R version 3.2.5 software for statistical computation. Study instruments had good validity and reliability properties, PHQ-9, r = .74, p = .015; AIDS-related Stigma, r = .85, p =.002 and Patient Adherence Record, κ = .7, p = .010. Data analysis was done using descriptive statistics and inferential statistics including: Mann-Whitney U test, Generalised estimating equations/GEE, Ordinal regression, Shapiro-Wilk W test for normality and Pearson’s χ2. The study established that CBT had a significant clinical effect and remission on depression (a mean drop of 5.8 points in PHQ-9 score from pre-to-posttest, p =.001); increasing ART adherence; OR = 2.14, 95% CI [1.31, 3.46]; and containing the escalation of HIV stigma as well as marginally lowering HIV internalised stigma (p =.051) among participants. The study also found a relatively large treatment effect size, r = .5 for CBT on depression and medium treatment effect size, r = .4 for CBT on ART adherence at month-2 posttest assessment. From the study results, it was concluded that CBT intervention was more effective for depression than the untreated control group, and that CBT participants had relatively better clinical outcomes for depression and medication adherence in the short term assessment. The study findings were important in providing empirical evidence in support for adaptation and application of group CBT as an effective psychological treatment for depression; and as an enhancer for medication adherence among PLHIV attending outpatient clinics in western Kenya. The study recommends that the Ministry of Health and agencies implementing HIV programmes should consider making necessary policies which may facilitate the integration of psychotherapy services into the routine HIV care to help patients deal with mental disorders that usually present along with HIV infection.