Emerging role for pharmacogenomics in HIV research in Africa

Tweetable abstract

Pharmacogenomics (Pgx); the study of how genes affect drug response may optimize treatment by improving effectiveness and safety of medications. To apply current guidelines for African HIV-infected patients Pgx research is key.

Effectiveness of a psychological intervention delivered by general nurses for alcohol use disorders in people living with HIV in Zimbabwe: a cluster randomized controlled trial

INTRODUCTION

There have been very few randomized clinical trials of interventions for alcohol use disorders (AUD) in people living with HIV (PLWH) in African countries. This is despite the fact that alcohol use is one of the modifiable risk factors for poor virological control in PLWH on antiretroviral therapy.

METHODS

Sixteen clinic clusters in Zimbabwe were selected through stratified randomization and randomized 1: 1 to Intervention and Control arms. Inclusion criteria for individual participants were being adult, living with HIV and a probable alcohol use disorder as defined by a score of 6 (women) or 7 (men) on the Alcohol Use Disorders Identification Test (AUDIT). In the Intervention clusters, participants received 8 to 10 sessions of Motivational Interviewing blended with brief Cognitive Behavioural Therapy (MI-CBT). In the control clusters, participants received four Enhanced Usual Care (EUC) sessions based on the alcohol treatment module from the World Health Organisation mhGAP intervention guide. General Nurses from the clinics were trained to deliver both treatments. The primary outcome was a change in AUDIT score at six-month post-randomization. Viral load, functioning and quality of life were secondary outcomes. A random-effects analysis-of-covariance model was used to account for the cluster design.

RESULTS

Two hundred and thirty-four participants (n = 108 intervention and n = 126 control) were enrolled across 16 clinics. Participants were recruited from November 2016 to November 2017 and followed through to May 2018. Their mean age was 43.3 years (SD = 9.1) and 78.6% (n = 184) were male. At six months, the mean AUDIT score fell by -6.15 (95% CI -6.32; -6.00) in the MI-CBT arm, compared to a fall of - 3.09 95 % CI - 3.21; -2.93) in the EUC arm (mean difference -3.09 (95% CI -4.53 to -1.23) (p = 0.05). Viral load reduced and quality of life and functioning improved in both arms but the difference between arms was non-significant.

CONCLUSIONS

Interventions for hazardous drinking and AUD comprising brief, multiple alcohol treatment sessions delivered by nurses in public HIV facilities in low-income African countries can reduce problematic drinking among PLWH. Such interventions should be integrated into the primary care management of AUD and HIV and delivered by non-specialist providers. Research is needed on cost-effectiveness and implementation of such interventions, and on validation of cut-points for alcohol use scales in low resource settings, in partnership with those with lived experience of HIV and AUD.

Mentored postdoctoral training in Zimbabwe: A report on a successful collaborative effort

Low-and-middle-income countries (LMICs) have high disease burdens, necessitating increased research. However, LMIC research output constitutes only 2% of global total. To increase output, researchers must be capacitated. The University of Zimbabwe (UZ) and the University at Buffalo (UB), developed and implemented the AIDS International Research Training Program (AITRP), in 2008, that focused on graduate scholars. The subsequent HIV Research Training Program (HRTP), begun in 2016, and piloted post-doctoral training to enhance research productivity at UZ. This report discusses the collaboration. As of 2016, prospective candidates applied by submitting letters of intent, research proposals, curriculum vitae and biographical sketches. The scholars research training included hypothesis and project development, completion of grant applications, research project budgets, research presentations to diverse audiences and the application of advanced statistics to research data. The first cohort of five postdoctoral scholars were trained at UZ and UB, between 2016 and 2019. Through the formalized postdoctoral training approach, scholars identified areas of focus. In 2017, one of the scholars obtained a National Institutes of Health (NIH) Emerging Global Leader Award and is now a highly-rated researcher based in South Africa. A second scholar made NIH D43 and K43 grant applications, while the remaining three are academicians and early researchers at UZ. Although research output in Africa and many LMICs is low, it can be built through cooperation similar to the UZ-UB HRTP. This manuscript reports on an effort aimed at building individual and institutional research capacity in Zimbabwe. This can serve as a model for building other similar training programs.

Psychological interventions for alcohol use disorders in people living with HIV/AIDS: a systematic review

BACKGROUND

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.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD  42017063856 .

Intervention for alcohol use disorders at an HIV care clinic in Harare: a pilot and feasibility study

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. Trial registration Pan African Clinical Trial Registry, current PACTR201509001211149.

Prevalence of depression and anxiety among undergraduate university students in low- and middle-income countries: a systematic review protocol

BACKGROUND

Depression and anxiety symptoms are reported to be common among university students in many regions of the world and impact on quality of life and academic attainment. The extent of the problem of depression and anxiety among students in low- and middle-income countries (LMICs) is largely unknown. This paper details methods for a systematic review that will be conducted to explore the prevalence, antecedents, consequences, and treatments for depression and anxiety among undergraduate university students in LMICs.

METHODS

Studies reporting primary data on common mental disorders among students in universities and colleges within LMICs will be included. Quality assessment of retrieved articles will be conducted using four Joanna Briggs critical appraisal checklists for prevalence, randomized control/pseudo-randomized trials, descriptive case series, and comparable cohort/case control. Meta-analysis of the prevalence of depression and anxiety will be conducted using a random effects model which will generate pooled prevalence with their respective 95% confidence intervals.

DISCUSSION

The results from this systematic review will help in informing and guiding healthcare practitioners, planners, and policymakers on the burden of common mental disorders in university students in LMICs and of appropriate and feasible interventions aimed at reducing the burden of psychological morbidity among them. The results will also point to gaps in research and help set priorities for future enquiries.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017064148.

Perceptions of alcohol use in the context of HIV treatment: a qualitative study

Background

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.

A 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

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.

TRIAL REGISTRATION

Pan African Clinical Trial Registry, PACTR201509001211149 . Registered 22 July 2015.