Improving the Treatment of Depression among Youth with HIV - PROJECT SUMMARY/ABSTRACT Depression is a common psychiatric condition among Youth with HIV (YWH), with prevalence as high as 25% in the United States. It has been shown to reduce adherence to antiretroviral treatment (ART), increase risk of disease progression, increase caregiver burden, increase healthcare costs, and decrease quality of life. Fortunately, there is an efficacious treatment. Practice guidelines and substantial research (including for those with HIV), indicate that measured-care treatment (care decisions guided by measures of symptomatology) using combination of a medication management algorithm and cognitive behavioral therapy (CBT) that is tailored to the population is very effective at reducing depression. In two prior studies with YWH, we have successfully trained clinicians in this tailored, measured-care, CBT, and medication management approach (COMB) and the outcomes have been impressive. For example, our cluster-randomized RCT at 13 HIV care sites found that the proportion of youth with a treatment response (symptom decrease > 50% from baseline) was significantly greater at COMB sites compared to treatment as usual (TAU) sites (62% vs. 18%, p <0.001) at Week 24. We were attentive to processes important to implementation, and used four Expert Recommendation for Implementing Change (ERIC) strategies: promoting adaptability, developing educational resources, providing clinical supervision, and changing the record system. Despite our use of these implementation strategies, by Week 48 depression rates in COMB had not continued to improve indicating a “voltage drop” of COMB’s impact and program “drift.” Because of the need to enhance sustainability, we propose testing COMBEX (COMB with additional implementation strategies to those previously used) compared to COMB in a Hybrid Type 2 Cluster Randomized Trial. Guided by the Consolidated Framework for Sustainability Constructs in Healthcare, COMBEX will be enhanced by using five additional ERIC strategies: 1) facilitating the relay of clinical data to providers; 2) reexamining clinical practices; 3) providing educational material in real time using sustainable technology; 4) providing supervision to enhance fidelity; 5) reminding clinicians about adherence with prompts. The trial will also test the real-world effectiveness of COMBEX in reducing indices of depression compared to COMB. To our knowledge, this will be the first project to examine implementation outcomes in depression treatment among YWH and among the few to test the effectiveness of treatment of depression in improving viral load (VL) suppression for YWH.
