The mental health of HIV-positive adolescents

In The Lancet Psychiatry, Khameer Kidia and colleagues propose that carefully selected and trained adolescents living with HIV can effectively help the delivery of mental health care for other adolescents living with HIV. We concur, and want to bring attention to a National Institute of Child Health and Human Developmentfunded project in Kigali, Rwanda, where we are doing exactly what Kidia and colleagues recommend: trained HIV-positive Rwandan youths deliver a trauma-informed cognitive behavioural intervention to improve adherence to antiretroviral therapy in young people with HIV. Since 2004, Women’s Equity in Access to Care and Treatment (WEACTx) has provided integrated primary care to women, men, and children with HIV. Psychosocial services and support groups are an essential component of culturally sensitive quality care. HIV-positive youths attend support groups to develop social support and gain knowledge about HIV. Since 2010, adolescents aged 19 years and older have been trained as so-called peer parents to help counsellors in leading activities and discussions with younger youths. After observing successful engagement of peer parents and youths, we developed a youth-led group-based intervention to improve medication adherence in 14–21-year-olds at WE-ACTx and University Teaching Hospital of Kigali (CHUK) youth programmes. In January, 2013, we initiated a randomised controlled trial to assess a six-session youth-led intervention to increase antiretroviral therapy adherence compared with usual care. Working closely with Rwandan mental health providers and adolescents living with HIV, a US-based psychologist adapted an evidence-based intervention for the Rwandan context. The intervention addresses knowledge about HIV; safer sex practices; stigma; gender-based violence; trauma; cognitive behavioural strategies that promote learning connections between thoughts, feelings, and behaviours; and problemsolving skills to resolve adherence obstacles. Movement-based relaxation techniques are also practiced. 18 youth leaders from peer parent groups were selected from the WEACTx and CHUK youth programmes. Rwandan-trained psychologists with BA qualifications were recruited to supervise the youth leaders. The USA-based psychologist provided 14 days of training for the youth leaders, assisted by the psychologists, to teach the curriculum, practice the intervention strategies, review group dynamics and leadership skills, and receive feedback to improve their facilitation. Ongoing supervision is provided by a cascade approach, in which the US psychologist has weekly Skype calls with the psychologists who then supervise the youth leaders twice per week. In-person consultations with youth leaders and psychologists take place biannually. At study midpoint (April 4, 2015), 198 youths have completed baseline assessments, of whom 99 remain in usual treatment and 99 in intervention groups. After the 6-month and 12-month assessments, participants will attend a youth-led booster session and will be re-assessed at 18 months. Fidelity data collected by self-reports and observer reports for ten groups showed good observance to and delivery of the curriculum. Therefore, our experience supports the idea that adolescents living with HIV can eff ectively and with fi delity lead mental health interventions for HIV-infected youths. We are encouraged by the enthusiasm, competence, and confidence of the youth leaders during their training and their skill as intervention facilitators. We believe that adolescents living with HIV will have an important role in improving HIV care for themselves and other aff ected youths.