E Kinyanda, MRC/UVRI Uganda Research Unit on AIDS - Mental health among HIV infected CHildren and Adolescents in KAmpala, Uganda (CHAKA)

Lead Research Organisation: London Sch of Hygiene and Trop Medicine
Department Name: Epidemiology and Population Health

Abstract

HIV disproportionately affects children and adolescents in sub-Saharan Africa, where 90% of those infected reside. In Uganda, the country with the fifth highest prevalence rate in the region, more than 10% of the 1.2 million people living with HIV are under the age of 15. In addition to its physical impact, HIV infected children and adolescents (CA-HIV) report poor mental wellbeing. Epidemiological research from high-income countries has found high rates of psychiatric disorder (PD; e.g. depression, anxiety and behaviour disorders). Evidence on risk factors for PD in CA-HIV remains inconclusive. However, potential risk factors include: poor maternal health; HIV disease severity; caregiver PD; HIV related neurological/developmental disability; stigma, death in the family and negative environmental factors; pain; and genetic factors. Although sub-Saharan Africa shoulders the greatest burden of youth HIV, little research has been conducted to better understand psychiatric problems among CA-HIV in the region. The aim of this study is to investigate the impact of PD on CA-HIV in Uganda and the implications for service provision.

The objectives of this study are to: (1) determine the prevalence, 12-month incidence and predictors of PD (including neurocognitive impairment) among CA-HIV; (2) investigate the relationship between differences in the serotonin transporter gene and depressive disorder; (3) examine the impact of PD on HIV disease progression; (4) examine the impact of PD on social and academic functioning and risky behaviours (i.e. treatment adherence, alcohol use, sexual behaviour and suicidal behaviour); and (5) investigate help-seeking behaviour and identify service delivery gaps in Ugandan HIV services. These objectives will be met through a cohort study of 1,260 CA-HIV and their caregivers from two paediatric HIV clinics in urban and rural Uganda. Socio-demographic characteristics and psychosocial, clinical, genetic and biological data will be collected by trained psychiatric research nurses and study clinicians at baseline and six and 12 month follow-up.

Nested in the cohort, we will carry out a qualitative sub-study of 48 CA-HIV diagnosed with a psychiatric disorder (PD) and their caregivers to investigate explanatory models of PD help-seeking behaviour, unmet needs of care and expectations from mental health care services. Interviews will be conducted on two occasions, within two months of baseline assessment and at 12 month follow-up.

HIV care services in Uganda are currently in the process of transitioning from a vertical care structure to one fully integrated into the formal health care system which focuses on the needs of people living with HIV/AIDS. The results of this timely study will provide policymakers and service providers with invaluable information to strengthen the provision of appropriate and effective mental health care for this vulnerable group.

Technical Summary

Prevalence/incidence of the broad categories of emotional and behavioural disorders, sub-diagnostic categories (including neurocognitive impairment) will be estimated with 95% confidence limits, overall and by site location, age-group and gender. A hierarchical approach will be used to investigate factors associated with PD.

The impact of PD on HIV disease progression on CA-HIV on antiretroviral treatment (ART) will be assessed using a linear mixed model fitted to the longitudinal data consisting of transformed CD4 counts at baseline and six and 12 months, with fixed terms for the presence/absence of PD, gender, age (as a continuous variable) and other prognostic factors, and a random effect for subject. For those not on ART, a binary variable will record whether or not the viral load is greater than 1,000 copies/ml. A similar analysis will then be carried out, except a generalised linear mixed model (GLMM) will be fitted.

The relationship between polymorphisms of the serotonin transporter gene and depressive disorder will be evaluated using mixed-effects logistic regression. We will use a stepwise selection procedure using the Akaike information criteria to select the specific combination of interactions and main effects out of the candidate model containing all individually significant factors.

To assess the impact of PD on social and academic functioning and risky behaviours, these outcome measures will be transformed into binary variables (e.g. the dichotomised "poor academic functioning") and then GLMMs will be fitted to the longitudinal data at each time point (i.e. baseline and six and 12-month follow-up).

Forty-eight CA-HIV diagnosed with a psychiatric disorder (PD) and their caregivers will be asked to participate in the qualitative sub-study. Thematic analysis will be conducted to elicit common experiences that emerged from the participants' narratives. In addition simple frequencies will be tallied for the various symptoms described.

Planned Impact

The proposed study will be the largest study addressing mental health of CA-HIV, and the first longitudinal study on their impact, in the sub-Saharan Africa. The impact of this research is anticipated at a number of levels and beneficiaries include service users, caregivers, policymakers, service providers, clinicians, research funders and communities. The primary impact will be a major contribution to knowledge of the burden of psychiatric disorder (PD) and neurocognitive impairment (NI) among children and adolescents living with HIV/AIDS (CA-HIV) in the sub-Saharan African setting of Uganda and the impact of these disorders on HIV disease progression and on risky behaviours. The study will also inform gaps in mental health service provision and lay the foundation for the development of appropriate mental health services, integrated within routine HIV care for CA-HIV. This is especially important in Uganda where HIV services are currently transitioning from a vertical care structure to one fully integrated into the formal health care system and focused on the needs of people living with HIV/AIDS.

The resulting prevalence data and information on the impact of psychiatric disorder (PD) and neurocognitive impairment (NI) might be used by research funders in the short term (3-5 years) to assist in decisions regarding research priorities.

Although the proposed project will largely provide epidemiological data, coupled with the qualitative data extracted from interviews, the results may lead to improvements in service user outcomes in the short and medium term (3-10 years) through improved accessibility and quality of interventions for psychiatric disorders and symptoms. The potential for improving interventions and service provision for CA-HIV with PD or even those displaying only symptoms based on the findings of this research may lead to greatly improved service user and caregiver outcomes (e.g. quality of life and productivity) resulting in economic and social benefit within their communities. The study investigators plan to use the CHAKA study findings to mount an intervention study aimed at addressing mental health problems in CA-HIV and reducing long-term adverse impacts.

The capacity building activities nested have been developed to improve the research and professional skills of members of the research team. Two members of the research team will be selected to undertake a distance learning Master's degree in Epidemiology from the London School of Hygiene and Tropical Medicine. During their course they will also have the opportunity to spend five weeks at the School to take a module, meet other students and receive face-to-face support and supervision from their tutor. In addition they will meet members of the Centre for Global Mental Health. It is anticipated that through this experience, they will begin to form professional relationships and collaborations with UK researchers with similar experiences. The ARL candidate (EK) will complete a six-week UK placement at the Centre for Global Mental Health at LSHTM during the grant. This experience will provide opportunities to present the project to UK researchers and clinicians, receive face-to-face mentoring and assistance with research management and writing up, build upon collaborations within the Centre and learn about mental health research and service provision for CA-HIV at two of the leading paediatric HIV clinics in the UK (Mortimer Market and Great Ormond Street Hospital clinics).

Publications

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Akotia CS (2019) Reasons for attempting suicide: An exploratory study in Ghana. in Transcultural psychiatry

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Kinyanda E (2018) Major Depressive Disorder: Longitudinal Analysis of Impact on Clinical and Behavioral Outcomes in Uganda. in Journal of acquired immune deficiency syndromes (1999)

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Kuteesa MO (2014) Experiences of HIV-related stigma among HIV-positive older persons in Uganda--a mixed methods analysis. in SAHARA J : journal of Social Aspects of HIV/AIDS Research Alliance

 
Description Child and adolescent mental health policy guidelines
Geographic Reach National 
Policy Influence Type Membership of a guideline committee
URL http://library.health.go.ug/publications/service-delivery-sexual-and-reproductive-health/adolescent-...
 
Description Engagement with Mental Health Coordinator at the Ministry of Health Uganda on mental health of children and adolescents with HIV/AIDS
Geographic Reach National 
Policy Influence Type Gave evidence to a government review
 
Description German Forum 2017
Geographic Reach Europe 
Policy Influence Type Gave evidence to a government review
 
Description 10. MRC Global Challenge Research Fund Foundation Grant
Amount £585,692 (GBP)
Funding ID MR/P023894/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 01/2017 
End 04/2019
 
Description Implementation Research for improved adolescent health in low and middle income countries
Amount £674,108 (GBP)
Funding ID MR/P011446/1 
Organisation Medical Research Council (MRC) 
Sector Academic/University
Country United Kingdom
Start 01/2017 
End 12/2020
 
Description Senior Wellcome Trust Fellowship in Public Health and Tropical Medicine
Amount £2,021,099 (GBP)
Funding ID 205069/Z/16/Z 
Organisation Wellcome Trust 
Department Wellcome Trust Bloomsbury Centre
Sector Academic/University
Country United Kingdom
Start 02/2017 
End 12/2021
 
Description U19 Scale up mental health interventions in low and middle income countries
Amount $2,500,000 (USD)
Organisation National Institutes of Health (NIH) 
Sector Public
Country United States
Start 07/2017 
End 06/2022
 
Description Wellcome Trust Principal Research Fellowship
Amount £3,750,000 (GBP)
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 10/2015 
End 09/2020
 
Title Adaptation and validation of the Child and Adolescent Symptom Inventory-Progress Monitor (CASI-PM) for use in Uganda 
Description We are undertaking the local adaptation and validation of a brief DSM-5 based tool, the Child and Adolescent Symptom Inventory-Progress Monitor (CASI-PM) for use in primary care settings in sub-Saharan Africa 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2019 
Provided To Others? No  
Impact Development is currently still underway 
 
Title Use of a DSM 5 based structured mental health assessment tool for children and adolescents 
Description We are, for the first time in Sub-Saharan Africa, using the CASI-5 (Children and adolescent Symptom Inventory-5) which is a DSM 5 based structured mental health assessment tool for children and adolescents. We undertook local adaptation of the CASI-5 before we used in our study. 
Type Of Material Model of mechanisms or symptoms - human 
Year Produced 2014 
Provided To Others? Yes  
Impact We shall be able to assess psychiatric disorder among Children and adolescents with HIV/AIDS using the most up to date diagnostic criteria 
URL http://www.checkmateplus.com/product/casi5.htm
 
Title CHAKA database 
Description As part of the CHAKA Study we have collected the biggest data on the psychiatric and neurocognitive problems of children and adolescents with HIV/AIDS in Uganda. We have data on 1,339 children collected at three time points: baseline, 6-months and 12-months. 
Type Of Material Database/Collection of data 
Year Produced 2016 
Provided To Others? Yes  
Impact Together with colleagues at London School of Hygiene and Tropical Medicine, UK, Stellenbousch University, South Africa and University of the Witwatersrand, South Africa we are in the process of writing up papers on the psychiatric and neurocognitive disorders of children and adolescents with HIV/AIDS. 
 
Description 2nd Annual Ugandan Conference of Child and Adolescent Mental Health, Kampala, Uganda 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Professional Practitioners
Results and Impact We presented a symposium on 'HIV and mental illness in children: findings from CHAKA study' (3 papers were presented by: i) Eugene Kinyanda: Psychiatric disorders among HIV infected children and adolescents in Uganda: the CHAKA study; ii) Richard Mpango: Prevalence and risk factors for ADHD and relation with social and academic functioning among children and adolescents with HIV/AIDS in Uganda; iii) Winifred Nalukenge: Knowledge and causal attributions for mental disorders in HIV positive children and adolescents); 27th -28th March 2017.
Year(s) Of Engagement Activity 2017
 
Description 3rd African College of Neuropsychopharmacology Congress (AfCNP), held in Kampala, Uganda 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact We presented a symposium on 'Global Mental Health Challenges' (4 papers were presented by: i) Eugene Kinyanda: Integrating the management of depression into routine HIV care in Uganda (the HIV+D trial); ii) Mr. David Kyaligonza: The role of Psychiatric Nurses in delivery of mental health services in Uganda; iii) Mr. Emmanuel Ngabirano : Improving access to mental health services among refugees: The experience of TPO; iv) Prof Atwoli Lukoye: Building capacity for mental health research in SSA); 18th-20th July 2017.
Year(s) Of Engagement Activity 2017
 
Description 11th World Congress on Adolescent Health, New Dehli, India 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Participated in the IAAH mental health session that was chaired by Prof Vikram Patel. Other speakers were:
• Meghna Khatwani (Student, Ambedkar University, Delhi, India)
• Eugene Kinyanda (Uganda Virus Research Institute, Entebbe, Uganda)
• Suzanne Petroni (International Center for Research on Women, Washington DC, USA)
This was an interactive panel discussion with active participation from panellists and the audience. The panel discussed some of the determinants of poor mental health in young people; the challenges of addressing the mental health needs of young people; and opportunities for addressing these needs, particularly in low and middle-income countries.
Year(s) Of Engagement Activity 2017
 
Description 1st Uganda National Child and Adolescent Mental Health Conference held on the 23rd -24th February 2015, Kampala 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact Richard Mpango a clinical psychologist with the CHAKA project made a presentation on the local adaptation of the Child and Adolescent Symptom Inventory (a childhood and adolescent psychiatric disorder assessment instrument) which was being used by the CHAKA Study for the first time in Uganda. The instrument was well received and we received many inquires from other scientist who were considering using the same.
Year(s) Of Engagement Activity 2015
URL http://www.thet.org/health-partnership-scheme/files/CAMHVFMcasestudy.pdf
 
Description A Global Ministerial Mental Health Summit in London, United Kingdom 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact Global Ministerial Mental Health Summit, 28th-30th September 2018, London United Kingdom where we launched the Lancet Commission Report on global mental health and sustainable development, 2018.
Year(s) Of Engagement Activity 2018
URL https://www.thelancet.com/commissions/global-mental-health
 
Description A consultative workshop 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact A consultative workshop on the topic, 'The development of a model to integrate mental health into adolescent HIV care services in Uganda' was held on the 18th April 2018 at the MRC/UVRI & LSHTM, Entebbe.
Year(s) Of Engagement Activity 2018
 
Description A discussion panel by the Academy of Medical Sciences and the InterAcademy Partnership for Health 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Eugene Kinyanda chaired the panel discussion on, 'Achieving the SDG goal of universal coverage for mental health care' at the workshop on, 'Mental health in low- and middle-income countries (LMICs)' jointly run by the Academy of Medical Sciences and the InterAcademy Partnership for Health from the 28th -29th June 2018, at the Academy of Medical Sciences, London, United Kingdom.
Year(s) Of Engagement Activity 2018
 
Description A workshop by the Harvard Medical School Center for Global Health Delivery in Dubai, UAE 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Convened a workshop by the Harvard Medical School Center for Global Health Delivery entitled, 'Scaling up community health worker-delivered interventions for common mental disorders' at the Mohammed Bin Rashid University (MBRU)/ Dubai Healthcare City, Dubai, United Arab Emirates from 23rd -25th June 2018.
Year(s) Of Engagement Activity 2018
 
Description EDCTP Forum 2017, Johannesburg South Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Gave a joint talk with the MRC/UVRI Director on the subject, ' What is good mentorship ? The experience of the
Eugene Kinyanda/ Pontiano Kaleebu'
Year(s) Of Engagement Activity 2017
 
Description Global Mental Health Strategy Meeting at the The Westminster Conference Centre, 5th October 2016 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact At this meeting which was called to discuss the strategic direction of the UK in terms of global mental health attracted leading scientist in this area in UK funded institutions. Eugene Kinyanda had the opportunity to share his work in Uganda and report on research areas where his Unit could participate in the future.
Year(s) Of Engagement Activity 2016
 
Description Global mental health seminar Series at the LSHTM presented by the ARL 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Increased awareness and stimulated debate about mental health aspects of HIV/AIDS

The ARL who presented this seminar received further inquires through email
Year(s) Of Engagement Activity 2014
 
Description Meeting of ARLs funded by the MRC/DFID African Leadership Scheme held at 8th EDCTP Forum, Lusaka Zambia 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact It was side meeting of the 8th EDCTP Forum held in Lusaka Zambia (6th-9th November 2016). At this side meeting ARLs including Eugene Kinyanda got to share their research projects, suceses so far attained, challenges and how they planned to advance their careers after the lifespan of the ARL.
Year(s) Of Engagement Activity 2016
URL http://www.edctpforum.org/
 
Description Out of the Shadows 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Policymakers/politicians
Results and Impact This was the first joint meeting of WHO and World Bank, hosted by the heads of both organizations, in Washington DC, to call for action on the evidence of the large unmet needs for care for mental disorders globally.
Year(s) Of Engagement Activity 2016
 
Description Symposium at the 20th World Congress of Epidemiology, 2014 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? Yes
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Outlined the role of mental health in the global health epidemiology agenda

Increased awareness about mental health issues
Year(s) Of Engagement Activity 2014
URL https://wce.confex.com/wce/2014/webprogram/meeting.html
 
Description World Psychiatric Association Regional Congress held in Cape Town South Africa, 17th-22nd September 2016 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Dr Noeline Nakasujja, Head of Department of Psychiatry, Makerere University and a collaborator on the CHAKA Study made a presentation derived from the CHAKA data on 'Anxiety disorders among HIV positive adolescents in Uganda'. The paper highlighted the burden of anxiety disorders among HIV infected children. It was well received and attracted many questions.
Year(s) Of Engagement Activity 2016
URL http://www.wpacapetown2016.org.za