Mental health issues such as depression, anxiety, and stress-related illnesses are ubiquitous, but their prevalence is notably high in Vietnam among people with HIV (PWH) who inject drugs. Studies indicate depression rates can range from 25% to 44%, amplifying HIV transmission and increasing negative outcomes. In response to a high burden of mental disorders globally and vast unmet need for mental health treatment in low- and middle-income countries, investigators with the UNC Institute for Global Health and Infectious Diseases are focused on task-shifting and integration approaches to care for common mental disorders (CMD). This shift equips non-specialists to deliver evidence-based mental health interventions at scale.
UNC Project-Vietnam, led by Bradley Gaynes, MD, MPH, Brian Pence, PhD, and Tran Viet Ha, MD, PhD, recently adapted the Friendship Bench program for people with opioid dependence and a CMD. The study, implemented in Hanoi from 2021 to 2023, was a three-arm randomized trial that assigned 75 participants to the Friendship Bench by a professional counselor, the Friendship Bench by a peer counselor, or enhanced usual care.
The trial took place at six Hanoi facilities with the highest number of HIV-infected individuals undergoing methadone treatment (Nam Tu Liem District Health Center, Hoang Mai District Health Center, Tay Ho District Health Center, Hanoi CDC in Ha Dong, Long Bien District Health Center and Hai Ba Trung District Health Center). Facility staff participated as counselors and community counselors were identified through a network of HIV peer educators.
Dr. Ha, the in-country director of UNC Project-Vietnam, explained more in the following interview.
Why was this study important?
“The presence of mental health issues significantly worsens health outcomes for PWH who inject drugs. They contribute to increased immune deficiency and mortality rates, while also negatively impacting adherence to HIV treatment and promoting risky behaviors like shared injecting equipment. Addressing these mental health challenges is crucial for improving both physical and mental well-being, ultimately enhancing the effectiveness of HIV and substance addiction treatments.
“There is also a distinct lack of published intervention programs designed to alleviate these issues. The “Friendship Bench” (FB) intervention, utilizing Problem Solving Therapy (PST), has demonstrated efficacy in reducing anxiety and depression in community settings and among people living with HIV in Zimbabwe. The Friendship Bench has also been successfully used to integrate depression screening and treatment into hypertension and diabetes care in Malawi (SHARP).
“At each facility in our study, individuals came in daily to take their medication, which included an examination, counseling, and periodic blood and urine tests as required. Before treatment, patients received one individual counseling session and three group education sessions. The purpose of counseling is to help patients gain a comprehensive overview of methadone treatment, make necessary preparations to ensure a safe and proper initiation of the dose, and advise patients to monitor for any abnormalities occurring within the first 4 hours of dose initiation, as well as provide information on HIV and relapse prevention.
How could the Friendship Bench support this population?
“Unlike routine care, the Friendship Bench offers consistent, weekly, targeted mental health counseling over six weeks. This approach has shown to significantly improve participants’ mental health symptoms, ultimately aiming to enhance their overall well-being and potentially improve adherence to HIV and methadone treatments. Its design emphasizes feasibility and cultural appropriateness for effective local implementation.”
How did you measure its success?
“The study successfully recruited and randomized the 75 participants within 6 months of the trial’s commencement. Primary outcomes were feasibility, acceptability, and fidelity of the Friendship Bench. We also assessed preliminary indicators of CMD improvement and HIV care engagement.
“Feasibility was high, with 99% retention at 6 weeks and 96% retention at 6 months. 100% of patients receiving FB attended all 6 weekly sessions. Acceptability of FB was high for participants in both the professional and peer counselor groups. Providers were highly satisfied with the FB experience. Fidelity was adequate: 72% of professional counselors met or exceeded fidelity expectations, while 44% of peer counselors did.
“Preliminary indicators of effectiveness for CMDs were promising. Participants in the professional counselor arm had the greatest improvement as measured by CMD symptom improvement and CMD response rates at most follow-up visits.
“Preliminary HIV care engagement outcomes at 6-months showed no clear difference between the three groups. Retention (94% kept visits) and ART status (93% were prescribed ART) were uniformly high. ART adherence was strong: 85% reported missing no doses and an additional 5% reported missing doses between 1 and 10% of the time. Most patients had viral load suppression (81%) at 6-months.”
Overall, what did the pilot intervention demonstrate?
“Findings suggest the intervention has significant potential and supports the need for a larger, fully powered randomized controlled trial to further evaluate its effectiveness. We may also want to perform studies that evaluate the effectiveness of the Friendship Bench with other populations in Vietnam and individuals who use other addictive substances like Amphetamine or synthetic drugs.”
Investigators with the Institute have also introduced the Friendship Bench to mental health care in Malawi. A five-year trial in Malawi used the Friendship Bench to support the integration of mental health with general medical care. Pence also led a mental health intervention that adapted the Friendship Bench for perinatal depression (Periscope). Gaynes adapted the Friendship Bench program for depressed adolescents with HIV (HEADS-UP)