An interactive, narrative intervention to address the mental health treatment gap among young people living with HIV in Nigeria

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PROJECT SUMMARY Young people living with HIV (Y-PLWH) have poor adherence to antiretroviral therapy and engagement in HIV care, making HIV the leading cause of death for African adolescents. Depression and psychological distress are much more common among Y-PLWH than in the general population, and are associated with significantly worse adherence to care and treatment when compared to Y-PLWH without these co-morbid conditions. Thus, untreated depression and severe psychological distress are important contributors to poor HIV outcomes in this population. Nigeria is home to the 4th largest HIV population globally and 10% of Y-PLWH, but mental health screening is not routinely conducted in this setting, and less than 10% of those diagnosed have access to evidence-based care. Despite this treatment gap, few interventions have targeted the mental health needs of Y-PLWH in Africa. The World Health Organization recommends that caregivers of Y-PLWH adopt youth- friendly strategies and incorporate psychosocial services to meet their needs, and that task shifting to non- specialized health workers be used to overcome the dearth of trained professionals in low and middle-income countries. Task-shifted problem Solving Therapy (PST) has been effectively used by our team and others to treat both depression and psychological distress using a task-shifted approach. However, PST is an intensive strategy (typically 6-15 weekly sessions) often delivered in-person and poor completion rates are associated with less effectiveness -- a concern further magnified during the current COVID-19 climate. Mobile health technologies may be uniquely suited to surmount some of the obstacles for effective PST delivery in Nigeria and novel digital game-based strategies, can be utilized to promote engagement in mental health interventions on a platform that is compelling for young people. Our team has developed, a preliminary prototype of a theory-grounded game, Change My Story, in which players navigate difficult experiences based on drivers of psychological distress and interact with a virtual environment to choose a narrative path toward the story's conclusion. In this proposal, we will finalize the prototype of Change My Story, and integrate this game into a comprehensive, task-shifted PST intervention delivered via mobile phone to optimize engagement in mental health care. Through the R21 mechanism, we aim to: 1) finalize the Change My Story prototype to address key drivers of psychological distress among Y-PLWH in Nigeria and 2) establish the usability, feasibility, and acceptability of Change My Story among Y-PLWH with psychological distress in Nigeria. Through the R33 mechanism, we aim to 1) conduct a hybrid implementation-effectiveness pilot RCT for 80 Y-PLWH with depression or psychological distress, and compare feasibility, acceptability, engagement, satisfaction and preliminary effectiveness among individuals receiving PST alone or PST with Change My Story, and 2) use the Consolidated Framework for Implementation Research (CFIR) to assess factors influencing engagement, acceptability, and satisfaction along with facilitators and barriers to implementation delivery.