Improving Adherence Among HIV+ Rwandan Youth: A TI-CBTe Indigenous Leader Model

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DESCRIPTION (provided by applicant): Like most of sub-Saharan Africa, Rwandan youth are the epicenter of the AIDS epidemic, accounting for 40% of new infections. Antiretroviral (ART) adherence is a global health priority, but Rwandan youth are more than twice as likely to be on second line therapy as adults, and with a median population age of 18.7 years old, adherence is essential for Rwanda's future. Resources to provide youth-centered medical and psychosocial care are limited in Rwanda, and young people with HIV face many obstacles to adherence, namely the long-term consequences of genocide, depression, and gender-based violence, as well as logistical issues, negative attitudes, and insufficient parent/caregiver support. Preliminary data underscore the utility of culturally-adapted, trauma-informed cognitive behavioral therapy (TI-CBT) in reducing depression and traumatic distress among youth and adults in Rwanda. This project proposes a 2-arm RCT to test and compare the efficacy of adherence-enhanced TI-CBT (i.e., TI-CBTe) to usual care in increasing ART adherence among 350 Rwandan 14 - 21 year olds from the two clinics caring for the largest number of youth with HIV in Rwanda. Based on the Indigenous Leader Outreach Model, we will train 20 HIV+ indigenous youth leaders who are > 95% ART adherent (IYL) and supervising psychologists to deliver the intervention. Youth, caregivers, and IYL will complete baseline, 6-, and 12-month follow-up assessments to assess effects on adherence and important mediators (trauma, depression, gender-based violence). We will use an intent-to-treat analysis and a combination of regression techniques and other inferential statistical tests for contrasting means and proportions. We will analyze treatment outcomes using logistic and linear multiple regression models examining effects at 6- and 12- months separately, as well as a combined model with random effects for repeated measurements across time. This proposal answers a compelling need for innovative programs to increase ART adherence among HIV+ youth. If effective, the study will build Rwanda's capacity to provide much needed services; and, involvement by the Rwanda Biomedical Center will ensure wide dissemination.