Services for prevention of mother-to-child-transmission (PMTCT) of HIV have been scaled up across Uganda,
yet one in five new HIV cases still result from vertical transmission. This is in large part due to ~30% of HIV+
mothers not receiving PMTCT care; and of those who do, two-thirds do not adhere to the full PMTCT care
continuum. Over 30% of HIV+ pregnant women are clinically depressed, and depression has harmful effects
on adherence to the PMTCT care continuum, yet mental health care is absent in Ugandan antenatal care
(ANC) clinics, leaving depression rarely diagnosed and treated. Research is needed to establish a viable model for
treating depression in the context of PMTCT care, and to understand how depression treatment may mitigate
the harmful effects of depression on PMTCT adherence so that optimal pregnancy outcomes can be achieved.
While there is some evidence that depression treatment and depression alleviation improve adherence to
general HIV care processes, such benefits have not been evaluated in the more complex PMTCT care
continuum, which includes not only maternal ART use (both pre- and post-natal), but also child use of ART
prophylaxis, periodic child HIV testing, and uniform breast feeding. Building on our prior research in integrating
task-shifted depression care into HIV clinics in Uganda, and our use of problem solving therapy (PST) and
antidepressant therapy (ADT) for treating depression in low resource settings, administered by trained lay
persons and nurses, respectively, this application proposes a cluster RCT to compare the effects of an
evidence-based depression care model vs. usual care on adherence to each step of the PMTCT care
continuum at 8 ANC clinics in Uganda. Usual care in Ugandan ANC clinics includes referrals to psychiatric
specialists in district hospitals, as well as the Ministry of Health’s Family Support Group (FSG) program for
HIV+ women, which provides psychosocial support through group education to help women adhere to PMTCT
care and manage their pregnancy. At the 4 experimental sites we will add to usual care the gold standard,
stepped care approach to providing evidence-based depression treatment consisting of PST (via individual
counseling, and content integrated into specific FSG group sessions) or ADT (for women with severe or
refractory depression, or who refuse PST). At each site, 50 HIV+ pregnant women (n=400) who screen positive
for potential depression will enroll and be followed until 18-months post-delivery. Primary outcomes consist of
maternal viral suppression and adherence to each step of the PMTCT care continuum. We will evaluate the
incremental cost-effectiveness of integrating evidence-based depression care, relative to usual care. If
efficacious and cost-effective, this study will provide a model for integrating depression care into ANC clinics
and promoting optimal adherence to the PMTCT care continuum and maternal and child health outcomes.