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

描述（由申请人提供）：像大多数撒哈拉以南非洲国家一样，卢旺达青年是艾滋病流行的中心，占新感染人数的40%。坚持抗逆转录病毒（ART）治疗是全球卫生优先事项，但卢旺达青年接受二线治疗的可能性是成年人的两倍多，而且卢旺达人口年龄中位数为18.7岁，坚持治疗对卢旺达的未来至关重要。在卢旺达，提供以青年为中心的医疗和心理社会护理的资源有限，感染艾滋病毒的青年在坚持治疗方面面临许多障碍，即种族灭绝、抑郁和基于性别的暴力的长期后果，以及后勤问题、消极态度和父母/照顾者支持不足。初步数据强调了文化适应性、创伤知情认知行为疗法（TI-CBT）在减少卢旺达青少年和成年人的抑郁和创伤困扰方面的效用。该项目提出了一项两组随机对照试验，以测试和比较依从性增强的TI-CBT（即TI-CBTe）与常规治疗在提高抗逆转录病毒治疗依从性方面的疗效，这些患者来自卢旺达两家治疗艾滋病毒青年人数最多的诊所的350名14 - 21岁卢旺达儿童。根据土著领袖外展模式，我们将培训20名艾滋病毒阳性的土著青年领袖，他们的抗逆转录病毒治疗依从率达到95%，并监督心理学家提供干预措施。青年、照料者和青少年援助青年将完成基线、6个月和12个月的随访评估，以评估对依从性和重要中介因素（创伤、抑郁、性别暴力）的影响。我们将使用意向治疗分析，结合回归技术和其他推论统计检验来对比均值和比例。我们将使用logistic和线性多元回归模型分别分析6个月和12个月的治疗效果，并使用随机效应的组合模型进行跨时间重复测量。这一建议回应了迫切需要的创新方案，以提高艾滋病毒阳性青年的抗逆转录病毒治疗依从性。如果有效，这项研究将建立卢旺达提供急需服务的能力；卢旺达生物医学中心的参与将确保广泛传播。

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.