Treatment outcomes of a stage 1 cognitive–behavioral trial to reduce alcohol use among human immunodeficiency virus‐infected out‐patients in western Kenya

Abstract

Aims Dual epidemics of HIV and alcohol use disorders, and a dearth of professional resources for behavioral treatment in sub-Saharan Africa, suggest the need for development of culturally relevant and feasible interventions. The purpose of this study was to test the preliminary efficacy of a culturally adapted 6-session gender-stratified group cognitive-behavioral therapy (CBT) intervention delivered by paraprofessionals to reduce alcohol use among HIV-infected outpatients in Eldoret, Kenya. Design Randomized clinical trial comparing CBT against a usual care assessment only control Setting A large HIV outpatient clinic in Eldoret, Kenya, part of the Academic Model for Providing Access to Healthcare collaboration Participants 75 HIV-infected outpatients who were antiretroviral (ARV)-initiated or ARV-eligible and who reported hazardous or binge drinking Measurements Percent drinking days (PDD) and mean drinks per drinking days (DDD) measured continuously using the Timeline Followback Findings There were 299 ineligible and 102 eligible outpatients with 12 refusals. Effect sizes of the change in alcohol use since baseline between the two conditions at the 30-day follow-up were large (d=.95, p=.0002, mean difference=24.93 (95% CI: 12.43, 37.43) PDD; d=.76, p=.002, mean difference=2.88 (95% CI: 1.05, 4.70) DDD). Randomized participants attended 93% of the 6 CBT sessions offered. Reported alcohol abstinence at the 90-day follow-up was 69.4% (CBT) and 37.5% (usual care). Paraprofessional counselors achieved independent ratings of adherence and competence equivalent to college-educated therapists in the U.S. Treatment effect sizes were comparable to alcohol intervention studies conducted in the U.S. Conclusions Cognitive-behavioral therapy can be successfully adapted to group paraprofessional delivery in Kenya and may be effective in reducing alcohol use among HIV-infected Kenyan outpatients.

The Systematic Development and Pilot Randomized Evaluation of Counselling for Alcohol Problems, a Lay Counselor‐Delivered Psychological Treatment for Harmful Drinking in Primary Care in India: The PREMIUM Study

“…The only comparable effort to develop a PT for alcohol problems in an LMIC was an effort to adapt CBT for alcohol use among HIV‐infected outpatients in Kenya (Papas et al., 2011). This study had several similarities with PREMIUM, for example, the substantial time spent on the development of the treatment; triangulation of data collected using mixed methods from diverse stakeholders; careful consideration of issues related to recruitment, training, competency evaluation, and maintenance of the counselors; and iterative use of data from the pilot study to refine the treatment.…”

“…A key difference was that while Papas and colleagues. (2011) started with an “off the shelf” treatment developed in Western settings, PREMIUM dismantled evidence‐based psychosocial treatments into their component strategies and added contextually appropriate strategies to create a pool of strategies which formed the basis for a new treatment.…”

Observational Research on NCDs in HIV-Positive Populations

“…For example, potential participants in a Kenyan randomized trial who were HIV-positive reported a high prevalence of hazardous and binge drinking when screened by a separate investigator, whereas a much lower prevalence was reported (particularly by women) after screening was transferred to the clinic nurse. 67 On investigation, it was observed that the nurse was asking women: “You don't drink alcohol, do you?” and asking men: “How much alcohol do you drink?”, introducing interviewer bias. 68 Clinic staff and patients may be fearful of violating societal norms, and patients may be concerned that accurately reporting use of alcohol, non-adherence to ART, or risky sexual behaviors might jeopardize their access to treatment.…”

Incorporating services for common mental disorders and substance use disorders for people living with HIV along the HIV treatment cascade

“…Effective, evidencebased treatments for CMDs and SUDs provide psychosocial support and patient stability creating a recovery platform promoting good clinical outcomes for long term ART. These treatments include both psychosocial therapy and pharmacotherapy [80][81][82][83]. Integration of treatment for CMDs and SUDs into HIV care and treatment programs results in good clinical outcomes and is cost effective [76,[84][85][86][87].…”