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| Name | Class |
|---|---|
| National Institute of Mental Health (NIMH) | NIH |
| Partners in Health | OTHER |
| Brigham and Women's Hospital | OTHER |
| Ministry of Health, Malawi |
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Malawi is a low-income country in sub-Saharan Africa that has limited resources to address a significant burden of disease-including HIV/AIDS. Additionally, depression is a leading cause of disability in the country but largely remains undiagnosed and untreated. Lack of cost-effective, scalable solutions is a fundamental barrier to expanding depression treatment. Against this backdrop, one major success has been the scale-up of a network of more than 700 HIV clinics, with over half a million patients enrolled in ART. As a chronic care system with dedicated human resources and infrastructure, this presents a strategic platform for integrating depression care, and responds to a robust evidence base outlining the bi-directionality of depression and HIV outcomes.
The investigators will evaluate a stepped model of depression care that combines group-based Problem Management Plus (group PM+) with antidepressant therapy (ADT) for 420 adults with moderate/severe depression in Neno District, Malawi, as measured by the Patient Health Questionnaire-9 (PHQ-9). Rollout will follow a stepped-wedge cluster randomized design in which 14 health facilities are randomized to implement the model in five steps over a 15-month period. Primary outcomes (depression symptoms, functional impairment, and overall health) and secondary outcomes (e.g. HIV: viral load, ART adherence; diabetes: A1C levels, treatment adherence; hypertension: systolic blood pressure, treatment adherence) will be measured every three months through 12-month follow-up. The investigators will also evaluate the model's cost-effectiveness, quantified as an incremental cost-effectiveness ratio (ICER) compared to baseline chronic care services in the absence of the intervention model.
This study will conduct a stepped-wedge cluster randomized trial to compare the effects of an evidence-based depression care model versus usual care on depression symptom remediation as well as physical health outcomes for chronic care conditions. The investigators will also look at the indirect effects of the intervention at the household level. The investigators' hypothesis is that the intervention will be effective at reducing depression symptoms, improving physical health, and improving household members' wellbeing, compare to treatment as usual. The investigators also hypothesize that the intervention will be highly cost-effective, meaning that the cost per QALY gained will be less than Malawi's median GDP per capita. If determined to be effective and cost-effective, this study will provide a model for integrating depression care into HIV clinics in additional districts of Malawi and other low-resource settings with high HIV prevalence.
BACKGROUND
Major depressive disorder imposes catastrophic health and economic impacts in Malawi, and throughout sub-Saharan Africa. Depression is a leading cause of disability in Malawi. Yet, best evidence suggests that over 90% of individuals with the condition receive no treatment (1). The cost of inaction is liable to have wide-ranging impacts. In terms of health, depression-when untreated-typically observes a recurrent trajectory across the lifespan, and is associated with significant depreciation in quality of life. Depression also indirectly impacts other health outcomes, including HIV outcomes such as adherence to antiretroviral therapy and health-seeking behavior. In terms of social ecology, depression affects interpersonal relationships, engagement in household activities, and labor force participation. The World Economic Forum has estimated a $30 trillion loss over a twenty-year span due to neglected treatment of neuropsychiatric conditions, largely due to lost labor force participation (2).
Integrating depression care into Neno's HIV platform represents a cost-effective, scalable solution in Neno District, Malawi, consistent with best practices. Over the past 10 years, Malawi has enrolled over a million individuals in antiretroviral therapy. Current enrollment levels stand at 580,000. This has been achieved by introducing a framework of HIV care delivery, the basis of which is a network of 706 HIV clinics throughout the country. Over this same timeframe, HIV has evolved from an acute condition with poor prognosis, to a chronic condition with vastly improved survival rates. Given this context, the HIV system is a strategic point of entry for screening and treating depression, as it represents a leveragable chronic care system. In Neno District, HIV facilities have already transitioned into an integrated chronic care platform for treating conditions like diabetes, hypertension, asthma and epilepsy. Likewise, community health screenings, routine in Malawi, could be leveraged to screen for depression.
Overarching Objective. Evaluate a clinical model of screening and treatment for depression in terms of 'real world' effectiveness and cost-effectiveness at reducing depression in Neno District.
Objective 1. Determine the implementation strategy effectiveness-in terms of improved depression (PHQ-9), daily functioning (WHODAS), and overall health (EQ5D)-of introducing a stepped model of depression care (behavioral therapy and antidepressant therapy) among adults receiving integrated chronic care in Neno District, Malawi between July 1, 2021-June 30, 2025.
Objective 2. Determine the cost-effectiveness the stepped model of depression care (behavioral therapy and antidepressant therapy) among adults receiving integrated chronic care in Neno District, Malawi between July 1, 2021-June 30, 2025.
Objective 3: Assess positive externalities associated with depression care, including improved wellbeing among household members of treated patients, and improved physical health outcomes among patients receiving depression care.
Objective 4: Inspect mediators and moderators of improved depression care, including a dose effect from level of treatment received (number of behavioral therapy sessions), reduced internalized mental health stigma, and improved perceived social support.
RATIONALE
The framework strategically addresses the bi-directionality of depression and HIV outcomes. A broad literature throughout sub-Saharan Africa has outlined the impact of HIV-including HIV-related stigma, reduced quality of life and ability to maintain employment-on elevated depression levels (3). Depression, in turn, predicts HIV-related outcomes such as adherence to ART. As such, targeting depression care among a population that includes HIV+ individuals in Malawi should yield significant benefits in terms of HIV-related outcomes. Outside sub-Saharan Africa, there is increasing evidence that integrative health services represents stronger value for money than stand-alone models.
Research examining the benefits and costs of treating neuropsychiatric conditions, including depression, suffers two key limitations. First, evaluations have only measured individual-level, direct treatment effects. This approach under-appreciates the social ecology of mental health: that individuals are typically situated within families, and families within communities. From this lens, neuropsychiatric disorders have shown adverse effects-in terms of burden of care and emotional wellbeing-on household members. Previously, the investigators showed that, when individuals' mental health improves through treatment, indirect benefits are observed among household members (4). Likewise, measurement limited to direct treatment effects overlooks indirect benefits to overall health, including for comorbid conditions such as HIV, that may result from mental health intervention. A second shortcoming is that evaluations have focused on measuring costs of standalone interventions, which are costlier than those that leverage existing systems. For instance, interventions for youth have often integrated within school systems to lower costs. In Malawi, the national HIV system-already transitioning to an integrated chronic care platform in Neno District-holds potential to treat depression at lower costs by building on established systems of longitudinal care.
In terms of historical objectives, a preponderance of mental health evaluations in low-resource settings has stopped at the point of measuring effectiveness, rather than cost-effectiveness, with a few exceptions by project members. The consequences are marked: In settings of financial constraint such as Neno District, Malawi, resources allocated to a particular program necessarily means resources allocated away from another. As such, assessing intervention costs are fundamental for determining scalability. A collaborative care model of treatment for depression and comorbid conditions such as HIV and diabetes has the potential to overcome resource constraints, which cost-effectiveness analysis would demonstrate.
The investigators will evaluate an evidence-based stepped care model of depression treatment integrated into Neno's HIV system, assessing health outcomes and cost-effectiveness, inclusive of direct and indirect benefits. Partners In Health (PIH), in collaboration with the Malawian Ministry of Health, has operated in Neno District-home to 165,000 Malawians-for 12 years. The investigators proposed to integrate a stepped care model for depression-combining antidepressant therapy (ADT) with group-based Problem Management Plus (PM+), the elements of which have been successfully instituted by the research team in low-resource settings, ranging from Rwanda to Haiti. The proposed study will evaluate a model that trains clinical staff situated in clinics to screen and diagnose depression, and administer PM+ among those with a diagnosis of moderate or severe depression. Over five weekly 1.5-2.5 hour group sessions, the behavioral intervention combines empirically-based treatment components such as psychoeducation, strategic problem solving, and behavioral activation (5). This will be coupled with antidepressant therapy (ADT) among those with severe depression.
To assess intervention benefits, the investigators will measure patient outcomes for depression every 3 months-including baseline, post-intervention, 6-months, and 12-months follow-up-as well as markers of comorbid conditions: including viral load and ART adherence among those are HIV+ (71% of the sample) as well as other disease-specific outcomes such as systolic blood pressure for hypertensive patients (17% of sample) and hemoglobin A1C for diabetic patients (2% of sample)-supported by an electronic medical records system. Importantly, to quantify indirect benefits of depression care, the investigators will also interview household members at baseline and 6-months follow-up to evaluate burden of care, including emotional distress and missed days of work. The investigators will convert direct and indirect benefits to quality-adjusted life years (QALYs).
METHODS
Design of Study. We will implement a stepped-wedge cluster randomized trial of an evidence-based intervention for depression care within Neno's HIV system, currently undergoing transition to a chronic care platform, examining depression symptoms and outcomes of comorbid conditions, inclusive of HIV, across 14 facilities rolled-out clinic-wide in five steps over 15 months (6). This design is a gold standard experimental approach aligned with PIH's clinical goal to implement depression care permanently throughout Neno District, and is a methodological framework on which we have unique expertise, including locally.
Place of Study. This study will take place in Neno District, a catchment area of 165,000 Malawians, where 12,186 are enrolled in integrated chronic care-including for HIV. Five-year retention in ART in Neno District is 80%, while five-year mortality is close to 15%. The viral suppression rate is 83%. These figures signify Neno as high performing but also underscores significant room for improvement-particularly among the most vulnerable, such as those with depression. As such, we do not anticipate a ceiling effect for measuring HIV outcomes among those concurrently enrolled in depression care. This is also true for other chronic conditions: e.g. only 60% of hypertensive patients currently have controlled systolic blood pressure (<140 mm Hg). Successes to-date have been achieved through modest human resource investments such as CHWs, suggesting replicability nationally. This has been supported by the investigators' past cost-effectiveness analyses.
Target Population. The investigators intend to recruit at least 420 adults with depression for participation in this study, beginning July 1, 2021 and continuing through June 30, 2025. This number is based on the sample size needed for us to determine the effectiveness of the depression treatment, as well as the prevalence of depression in Malawi: At each ICC clinic, 200-1,800 patients are seen on a quarterly basis. The investigators anticipate 10%-12% of all patients (n=12,186) will screen positive for depressive symptoms, and 6% will be diagnosed with moderate/severe depression. Prior studies in Malawi have found acceptance of research study participation is 90% or higher. In addition, the investigators will be conducting interviews with 210 households among half of participants-in order to determine whether the intervention improves quality of life within households.
Sampling Techniques and Tools. The full study period is January 1, 2021 through June 30, 2025. The first six months will be preparation. Beginning July 1, 2021, all adults attending integrated chronic care clinics will be screened for depression symptoms using the PHQ-2 by existing clinical officers. Consistent with the prior screening literature, those with a score > 2 will complete remaining questions of the PHQ-9; and a score >9 will trigger administration of a brief diagnostic interview--adapted from the CIDI 3.0--by a trained counselor. Those with PHQ-9<10 (no/mild depression) will receive a psychoeducation session, but will not be enrolled-based on limited availability of health professionals and need-based prioritization. Those with moderate/severe depression (PHQ-9>9, corresponding to diagnosis of major depression) will be eligible for cohort enrollment. Screening, diagnosis and enrollment will occur continuously across all facilities over the full trial period; those who meet diagnostic criteria will be enrolled. Treatment will be rolled-out progressively: patients in each cluster's cohort will be initiated into the intervention: Three facilities will begin treatment immediately (Step 1), with remaining facilities will initiate treatment at three- (Step 2), six- (Step 3), nine- (Step 4) or twelve-months (Step 5) later. The stepped-wedge approach enables all facilities throughout Neno District to implement the model, as such maintaining equipoise. Assessment of patients on outcome measures will occur at every 3 months.
Sample Size Determination. The investigators assume n=30 enrollees per facility (total n=420), based on depression prevalence in Malawi. The investigators further assume loss to follow-up of 15%, based on intervention trials that the investigators have conducted in similar settings. To account for clustering, the investigators calculated detectable differences using an intracluster correlation coefficient (ICC) of 0.05 within treatment group and 0.01 within rollout step, based on depression treatment studies in multiple developing countries, including the investigators' pilot work. Based on this, the investigators find n=420 enrollees to be sufficient (power > 0.80; (alpha=.05; 2-tailed) for detecting a clinically meaningful standardized effect size of 0.5 (Cohen's d) for primary outcomes, including accounting for cluster autocorrelation. This is not separated by modality (though the investigators will explore this): it is to assess overall effectiveness of the stepped care model.
Data Collection Techniques and Tools. Over the 15-month roll-out period, primary outcomes (PHQ-9, WHODAS, EQ5D) will be measured at three-month intervals among all participants from point of enrollment, consistent with the three-month increments between steps (see above). Three-month increments will coincide with treatment initiation, post-intervention, 6 months and 12 months follow-up. In the event an enrolled individual no longer meets criteria at treatment initiation, the individual will leave the cohort and not be eligible for treatment but will continue to be evaluated every three months for future eligibility. Given that screening, diagnosis and enrollment will occur at all facilities over the full trial period, the investigators expect any reduction in patients enrolled in the cohort due to lagged treatment initiation will be offset by newly-identified individuals over this same period. This is consistent with an open cohort design for stepped-wedge trials. Ultimately, this approach enables all facilities to implement the model, maintain equipoise, and create control sites by randomizing roll-out sequence. Measurement intervals are consistent with best practices in outcomes tracking, including past trials. Interviews with household members will be conducted at treatment initiation and 6-month follow-up, among 210 randomized households.
Data Analysis. Analysis will assume a mixed-effects longitudinal regression framework, which the team has implemented in similar contexts. To account for nesting of patients within treatment groups and clusters, as well as time points (autocorrelation), patient, patient group and cluster will be incorporated as random effects, while cluster assignment and covariates are included as fixed effects-using STATA's MIXED command. The investigators will run sensitivity analyses to test if data are missing at random (MAR), and examine stigma and social support as moderators, as well as potential mediation using causal mediation analysis.
Effectiveness. The investigators will use linear mixed-effects regression analysis to test differences between study arms on change in primary outcomes. Models will adjust for patient demographics, as well as stigma and social support. Analysis will assume an intention-to- treat (ITT) framework, with and without multiple imputation analysis. In addition to ITT, the investigators will perform a 'completers only' analysis to exam outcomes among those who adhered to treatment, and examine dose response.
Cost-effectiveness. Health measures will be converted to QALYs using the EQ5D-3L cross-walk between domain-specific outcomes. This approach has been utilized and published on previously. QALY estimates will be related to base case and treatment cost estimates. For formal CEA, the investigators will use a gold standard Markov chain Monte Carlo (MCMC) simulation-based approach in TreeAge, from a societal perspective. For sensitivity analyses, the investigators will vary discount rates from 0-5%, based on health-adjusted life expectancy. Unit of interest is the incremental cost-effectiveness ratio (ICER) of cost per QALY, comparing the cost of integrated chronic care before and after introduction of the depression treatment.
PROTOCOL
Evidence-based treatment of depression. Drawing from a manual-driven framework of enhanced Problem Solving Therapy (PST) known as Problem Management Plus (PM+), developed by the WHO for low-resource settings, the investigators will implement a gold standard, stepped approach to treatment for depression. The model will follow a group format, based on three considerations: this lowers costs of human resources, which is essential when considering national scalability; it provides peer support during treatment; and it is culturally appropriate for the setting. These considerations have been sources of advocacy for the group model by WHO. In settings where group format has been implemented, results have been comparable to individual format. Local counselors will administer PST in five 1.5-2.5 hour sessions, with 6-8 participants per group, consistent with WHO guidelines. Among those with PHQ-9>15, antidepressant therapy (ADT) will be offered following WHO mhGAP procedures.
Depression screening. The investigators will screen patients ages 18+ enrolled in ICC clinics in Neno District, beginning the first quarter of Y2. Screening, diagnosis and enrollment into the treatment cohort will occur continuously across facilities, administered by data clerks and counsellors trained on the PHQ-2 and PHQ-9, respectively (6). Screening will also occur every 3 months among individuals in the active cohort to determine current treatment eligibility status. The PHQ-2 assesses frequency of depressed mood and anhedonia, and has been implemented throughout Africa. Use of PHQ-2 as a first step has will save time: the investigators are screening 12,186 adults. The selected threshold allows high sensitivity. Patients who screen positive with the PHQ-2 (score >2; range: 0-6) will immediately receive remaining PHQ-9 questions, on which a score > 9 (range: 0-27) represents a possible depressive disorder. Those with PHQ-9<10 will receive a psychoeducation session from the clinical officer, using a manual on which they have been trained. Those with PHQ>9 (moderate/severe depression) will be referred to a counselor to administer the diagnostic protocol.
Depression diagnosis. Counselors will review PHQ-9 scores and administer a brief diagnostic interview--based on the Comprehensive International Diagnostic Interview (CIDI)--to diagnose depression: 5 of 9 symptoms present and functional impairment. All patients will be evaluated for suicide risk and whether immediate intervention is warranted. If so, they will be referred to the supervising physician at the health facility, triggering an emergency protocol. Patients will be assigned to one of three categories: mild, moderate and severe depression. Those with a negative diagnosis will not be eligible for the intervention, and will undergo PHQ-2 screenings at subsequent visits for eligibility. Those with a positive diagnosis and PHQ-9>10 will be eligible. Those with PHQ-9 10-14 will be offered PST alone. Those with PHQ-9>15 (moderate-to-severe depression) will be offered PST and ADT as joint treatment, with the alternative to choose a single modality. Pregnant women with severe depression will also be eligible for ADT. Best evidence, including recent systematic reviews, does not find increased risk for mother or infant with appropriately administered ADT, and there are significant potential benefits of improved wellbeing of the mother.
Psychoeducation and treatment selection. Counselors will inform patients on availability of PST and ADT, outline potential benefits and risks, provide an overview of the study, and acquire informed consent. Those who decline care will be offered psychoeducation and referred to available resources. Among those who elect PM+, the first PM+ session will also incorporate in-depth psychoeducation. Patients with a PHQ-9 score of 10-14 will be provided the option of ADT but recommended PM+ instead, given that behavioral therapy has established efficacy and avoids potential side effects of ADT. Patients with PHQ-9 > 15 will also be given the options of PST, ADT, or both, and recommended both. At facilities randomized to administer the intervention immediately, patients will be informed of date, time and location of their first PM+ session.
Problem Management Plus (PM+). Counselors (n=8) will receive intensive training in Year 1 by to administer PM+ using a manualized approach. Training and supervision are described below. PM+ is a WHO-enhanced framework of Problem Solving Therapy (PST) for implementation by lay personnel in low-resource settings like Neno, designed to be conducted in five weekly 1.5-2.5 hour sessions. Elements of PM+, including sequential problem solving, have been applied by the research team in numerous settings with marked success, including in Lilongwe. This district-wide randomized trial leveraging Neno's existing infrastructure would represent a critical evidential support for WHO's agenda to expand the model globally. Modules include: psychoeducation, managing problems, behavioral activation, social support strengthening, and stress reduction.
Antidepressant Therapy (ADT). The investigators expect 20-25% of study participants-i.e. those who meet diagnostic criteria-to have moderately severe or severe depression and opt to enroll in ADT. Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District has a robust supply chain, which will reduce stock-out. Potential side effects of ADT are modest but include nausea, insomnia, and nervousness and will be communicated to participants prior to initiation. There is modest evidence ADT may increase risk of suicidality; this risk will be stated in informed consents, counselors will be trained to identify this risk, and will be formally assessed during outcome assessments, with the potential to trigger protocol for suicidal ideation. Benefits of ADT often outweigh risk of harm and negative impact of untreated depression. Fluoxetine is typically the first drug of choice because it is better tolerated.
Dosing Algorithm: Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. Dose increments and levels are the same for each drug. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using the Antidepressant Side Effect Checklist. This algorithm-based process will be repeated bi-weekly until the patient is fully responding to treatment for a period of three months (PHQ-9 < 5). Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge.
MEASUREMENT
Primary Outcomes. Measures will include surveys, laboratory assays, pharmacy data, and data abstracted from medical charts and the Depression Care Registry. Survey measures that have not been translated into Chichewa in the course of prior research will be translated using standard translation, back-translation methods, and will be administered at each assessment, unless otherwise noted.
Depression symptoms. Depression symptoms will be measured with the PHQ-9, which has been translated previously and locally-validated. The investigators have elected to use PHQ-9 because it has been implemented throughout sub-Saharan Africa, including Malawi, where the scale has shown high sensitivity responding to treatment, as well as concurrent and predictive validity. It contains nine four-point ordinal response items on topics such as hopelessness, psychosomatic response (e.g. sleeplessness, loss of appetite) and anhedonia.
Functional impairment. Functional impairment including aspects of daily functioning, correspond to DSM diagnostic criteria. The investigators will evaluate this using the 12-item WHO Disability Assessment Schedule 2.0 (WHODAS). The WHODAS has been validated in a diverse range of sub-Saharan African contexts, including Malawi, and covers topics like completing household chores, concentrating, and maintaining relationships.
Overall health. A health profile will be generated for each individual using the EQ-5D-3L, previously validated in Malawi. This survey determines patients' overall health at time of interview and offers a cross-walk to quality-adjusted life years (QALYs).
Secondary Outcomes. Secondary outcomes will constitute those measuring indirect benefits and costs of treatment. Indirect benefits will be incorporated into cost-effectiveness estimates by internalizing improvements among comorbid conditions such as HIV and hypertension, as well as reduced household burden of care.
ART adherence. ART adherence will be measured in terms of whether HIV+ enrollees have returned to an IC3 for antiretrovirals (ARVs) within the past three months, an approach considered more reliable than self-reports. This interval overlays with clinical protocols throughout Malawi in terms of the duration for which ARVs are supplied.
Viral load. Viral load will be measured as part of HIV+ patients' clinical assessment pre-intervention, post-intervention, 6- and 12-month follow-up, consistent with ongoing care at IC3s. This is considered a key metric for determining treatment plans and is highly sensitive to compliance with prescribed ART regimens.
HIV disease staging. Staging will be evaluated every three months among HIV+ enrollees, consistent with IC3 visits. This approach to tracking disease progression is commonly used in low-resource settings.
Chronic care outcomes. Chronic care outcomes on hypertension, type-2 diabetes, and epilepsy will be abstracted from electronic medical records. Systolic blood pressure and adherence to antihypertensive medication (measured by medicine pickups) will be measured among those with hypertension. Among those with type-2 diabetes, adherence to quarterly visits and A1C (or random blood sugar) levels will be abstracted. Among those with epilepsy, the investigators will catalog number of reported seizures in past quarter, and adherence to antiepileptics as measured by quarterly medicine pickups.
Household burden of care. Lastly, household burden of care will be evaluated with household members using a locally-adapted version of the Burden Assessment Schedule (BAS), previously implemented by the team. The survey assesses dimensions of emotional and functional burden of care, including missed work, guilt and worry.
Mediators and Moderators. Analyses will also include three mediators/moderators assessing potential pathways by which depression treatment leads to alleviation of depression symptoms, including enhanced social support, reduced HIV and depression-related stigma, and performance of psychosocial counsellors as quantified by fidelity to PM+ protocols.
Perceived social support. Social support strengthening is a focus of PM+. This will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS), previously validated, to assess support before and after care.
Perceived stigma. Self-perceived stigma is associated with HIV status and depression, including in Malawi. The investigators will adapt the AIDS-Related Stigma Scale (ARSS) and Internalizing Stigma of Mental Illness (ISMI) scale in Year 1 of the project-both designed for use in community-based settings in sub-Saharan Africa.
PM+ fidelity. Fidelity checklist scores will be generated for each counsellor by a lead clinical officer or supervisor. Research has shown that fidelity protocols are predictive of patient outcomes in the context of depression care.
Household Interviews. Adult household members of participants-one per household-will be identified for participation based referral by the study participant and/or self-identification as a social support in close contact with the study participant. This individual will be informed that the research team is conducting a broad study on the relationship between individual and household health. Household interviews will chiefly comprise a subset of the battery administered to participants: specifically, the PHQ-9, WHODAS, and EQ-5D-3L (primary outcomes). In addition, household members will complete the BAS, as described above.
Process Evaluation. In the final year of the project, the investigators will conduct qualitative interviews to assess provider and patient experiences on their perceived effects of the intervention, as well as implementation barriers and strategies used to solve them. The goal is to identify key lessons learned, and to ready the intervention tools for scale-up at end of study.
Provider experience: In Year 5, the investigators will interview 10 clinical officers who prescribed ADT, as well as psychosocial counsellors who led PM+ sessions as well as diagnosed patients. In addition to discussing perceived strengths and weakness of the intervention and its implementation, the investigators will also discuss the training and supervision process, as well as provider job satisfaction and burnout.
Patient experience: A random sample of 20 participants (10 male, 10 female) will be interviewed after their final study assessment to assess their experiences with the intervention - including logistical aspect of participation, impact on personal mental health and wellbeing, as well as changes in relationships at the household level.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Cluster 1 (First Cluster of Clinics Randomized to Receive Care) | Experimental | Arm 1 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 3 of the trial |
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| Cluster 2 (Second Cluster of Clinics Randomized to Receive Care) | Experimental | Arm 2 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 6 of the trial |
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| Cluster 3 (Third Cluster of Clinics Randomized to Receive Care) | Experimental | Arm 3 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 9 of the trial |
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| Cluster 4 (Fourth Cluster of Clinics Randomized to Receive Care) | Experimental | Arm 4 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 12 of the trial |
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| Cluster 5 (Fifth Cluster of Clinics Randomized to Receive Care) | Experimental |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Problem Management Plus | Behavioral | PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems, and uses the term "problem management" rather than "problem solving" to emphasize that many problems encountered by individuals living in adverse circumstances may not be "solvable". The "plus" in PM+ underscores additional evidence-based behavioral strategies incorporated into the model, including: stress management strategies, behavioral activation, and social support strengthening. In total, PM+ comprises five sessions held once per week for 1.5. to 2.5 hours per session. The model has shown success in reducing depression symptoms in low-resource settings such as Nepal and Pakistan.4 |
| Measure | Description | Time Frame |
|---|---|---|
| Depression Symptoms (PHQ-9), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 3-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. | 3 months post-intervention for all participants (i.e., for each arm) |
| Depression Symptoms (PHQ-9), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 6-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. | 6 months post-intervention for all participants (i.e., for each arm) |
| Depression Symptoms (PHQ-9), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 9-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. | 9 months post-intervention for all participants (i.e., for each arm) |
| Depression Symptoms (PHQ-9), 12 Months Post-intervention for All Participants (i.e., for Each Arm). | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 12-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. |
| Measure | Description | Time Frame |
|---|---|---|
| ART Adherence (Medication Pick-Up Every 3 Months), 3-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. |
| Measure | Description | Time Frame |
|---|---|---|
| Perceived Burden of Care (BAS) Among Household Member, 6 Months After the Start of Study Participant Treatment Eligibility | Perceived burden of care will be measured according to the Burden Assessment Schedule (BAS). This will be quantified as household member's score at 6-months after initiation of treatment eligibility for the study trial participant. Scale Name: Burden Assessment Schedule Scale Range (Min-Max): 0-57 Scale Notes: Higher value indicates more severe perceived burden of care. There are no combined subscales. |
Inclusion Criteria:
Exclusion Criteria:
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| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Partners In Health | Neno | Neno District | Malawi |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 25157314 | Background | Udedi M. The prevalence of depression among patients and its detection by primary health care workers at Matawale Health Centre (Zomba). Malawi Med J. 2014 Jun;26(2):34-7. | |
| Background | World Economic Forum. The Global Economic Burden of Non-Communicable Diseases. World Economic Forum; Harvard School of Public Health; 2011. | ||
| 29768184 |
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De-identified participant data, a data dictionary, and accompanying analytic code will be made available on Harvard University's DataVerse at the conclusion of the trial. Participants will be made aware of this during the informed consent process and provide their consent.
Data will become available in July 2025 and remain available at Harvard's DataVerse indefinitely.
Access to data files on Harvard's DataVerse requires that researchers complete compliance and authorization forms.
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| ID | Title | Description |
|---|---|---|
| FG000 | Cluster 1 (First Cluster of Clinics Randomized to Receive Care) | Arm 1 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 3 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. In total, PM+ comprises five sessions held once per week for 1.5. to 2.5 hours per session. The model has shown success in reducing depression symptoms in low-resource settings such as Nepal and Pakistan.4 Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| FG001 | Cluster 2 (Second Cluster of Clinics Randomized to Receive Care) | Arm 2 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 6 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. In total, PM+ comprises five sessions held once per week for 1.5. to 2.5 hours per session. The model has shown success in reducing depression symptoms in low-resource settings such as Nepal and Pakistan.4 Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| FG002 | Cluster 3 (Third Cluster of Clinics Randomized to Receive Care) | Arm 3 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 9 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. In total, PM+ comprises five sessions held once per week for 1.5. to 2.5 hours per session. The model has shown success in reducing depression symptoms in low-resource settings such as Nepal and Pakistan.4 Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| FG003 | Cluster 4 (Fourth Cluster of Clinics Randomized to Receive Care) | Arm 4 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 12 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. In total, PM+ comprises five sessions held once per week for 1.5. to 2.5 hours per session. The model has shown success in reducing depression symptoms in low-resource settings such as Nepal and Pakistan.4 Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| FG004 | Cluster 5 (Fifth Cluster of Clinics Randomized to Receive Care) | Arm 5 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 15 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. In total, PM+ comprises five sessions held once per week for 1.5. to 2.5 hours per session. The model has shown success in reducing depression symptoms in low-resource settings such as Nepal and Pakistan.4 Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
Total enrollees
Not provided
| ID | Title | Description |
|---|---|---|
| BG000 | Cluster 1 (First Cluster of Clinics Randomized to Receive Care) | Arm 1 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 3 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Continuous | Mean |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Depression Symptoms (PHQ-9), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 3-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. | The outcome at 3 months post-intervention are reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 3 months post-intervention for all participants (i.e., for each arm) |
|
Up to 24 months. Those enrolled at sites commencing treatment at the latest date were observed for 24 months from enrollment, while those enrolled at sites commencing treatment at the earliest date were observed for 12 months from enrollment.
The definitions for adverse event and serious adverse events does not differ from clinicaltrials.gov definitions.
With respect to adverse event data collection: study participants were monitored continuously over the trial period (12-24 months per participant), based on review of medical record information within the electronic health records system of Partners In Health. In addition, participants were directly interviewed every 3 months.
Not provided
| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Cluster 1 (First Cluster of Clinics Randomized to Receive Care) | Arm 1 represents a cluster of 2-3 clinics randomized to begin delivering the intervention |
Not provided
Not provided
PIH was unable to collect data for two outcomes, leading to 0 participants analyzed: (1) WHO Staging, because National Guidelines were revised to focus on viral load; and (2) HbA1C, because supply chains were unable to store samples for transport. Earlier communication should have clarified that blood glucose (a proxy) was collected in some instances--but never HbA1c, the pre-specified outcome measure (this was only recently clarified by the field team). We thus don't have analyzable data.
| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Ryan McBain | RAND | (703) 413-1100 | rmcbain@rand.org |
Not provided
| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot | Yes | No | No | Study Protocol | Sep 20, 2021 | Sep 20, 2021 | Prot_002.pdf |
| SAP | No | Yes | No | Statistical Analysis Plan | Nov 18, 2021 | Nov 21, 2021 | SAP_004.pdf |
Not provided
| ID | Term |
|---|---|
| D003866 | Depressive Disorder |
| D003863 | Depression |
| ID | Term |
|---|---|
| D019964 | Mood Disorders |
| D001523 | Mental Disorders |
| D001526 | Behavioral Symptoms |
| D001519 | Behavior |
Not provided
Not provided
| ID | Term |
|---|---|
| D005473 | Fluoxetine |
| D000639 | Amitriptyline |
| ID | Term |
|---|---|
| D011437 | Propylamines |
| D000588 | Amines |
| D009930 | Organic Chemicals |
| D003986 | Dibenzocycloheptenes |
Not provided
Not provided
| OTHER_GOV |
| Blantyre College of Medicine | UNKNOWN |
| University of Birmingham | OTHER |
Stepped wedge cluster randomized trial
Not provided
Not provided
Those who are screening and diagnosing depression will not be made aware of the randomization sequence. Likewise, those assessing outcomes will not be made aware of the randomization sequence.
Arm 5 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 15 of the trial |
|
|
|
| Antidepressant Therapy | Drug | Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
|
|
| 12 months post-intervention for all participants (i.e., for each arm). |
| Functional Impairment (WHO Disability Assessment Schedule), 3 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 3-months (post-intervention). It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | 3 months post-intervention for all participants (i.e., for each arm). |
| Functional Impairment (WHO Disability Assessment Schedule), 6 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 6-months (post-intervention). It is not a change score. Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | 6 months post-intervention for all participants (i.e., for each arm). |
| Functional Impairment (WHO Disability Assessment Schedule), 9 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 9-months (post-intervention). It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | 9 months post-intervention for all participants (i.e., for each arm). |
| Functional Impairment (WHO Disability Assessment Schedule), 12 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 12-months (post-intervention). It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | 12 months post-intervention for all participants (i.e., for each arm). |
| Overall Health Profile (EQ-5D-5L), 3 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 3-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | 3 months post-intervention for all participants (i.e., for each arm). |
| Overall Health Profile (EQ-5D-5L), 6 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 6-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | 6 months post-intervention for all participants (i.e., for each arm). |
| Overall Health Profile, 9 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 9-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | 9 months post-intervention for all participants (i.e., for each arm). |
| Overall Health Profile, 12 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 12-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | 12 months post-intervention for all participants (i.e., for each arm). |
| Prevalence of Depression (PHQ-9 Score > 9), 3-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | 3 months post-intervention for all participants (for each arm). |
| Prevalence of Depression (PHQ-9 Score > 9), 6-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | 6 months post-intervention for all participants (for each arm). |
| Prevalence of Depression (PHQ-9 Score > 9), 9-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | 9 months post-intervention for all participants (for each arm). |
| Prevalence of Depression (PHQ-9 Score > 9), 12-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | 12 months post-intervention for all participants (for each arm). |
| 3 months post-intervention for participants with HIV (i.e., for each arm). |
| ART Adherence (Medication Pick-Up Every 3 Months), 6-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | 6 months post-intervention for participants with HIV (i.e., for each arm). |
| ART Adherence (Medication Pick-Up Every 3 Months), 9-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | 9 months post-intervention for participants with HIV (i.e., for each arm). |
| ART Adherence (Medication Pick-Up Every 3 Months), 12-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | 12 months post-intervention for participants with HIV (i.e., for each arm) |
| Viral Suppression (<500 Copies of the Virus Per mL of Blood), 3-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | 3-months post-intervention for participants with HIV (i.e., for each arm). |
| Viral Suppression (<500 Copies of the Virus Per mL of Blood), 6-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | 6-months post-intervention for participants with HIV (i.e., for each arm). |
| Viral Suppression (<500 Copies of the Virus Per mL of Blood), 9-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | 9-months post-intervention for participants with HIV (i.e., for each arm). |
| Viral Suppression (<500 Copies of the Virus Per mL of Blood), 12-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | 12-months post-intervention for participants with HIV (i.e., for each arm). |
| Controlled Systolic Blood Pressure (<140mmHg), 3-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | 3 months post-intervention for participants with hypertension (i.e., for each arm). |
| Controlled Systolic Blood Pressure (<140mmHg), 6-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | 6 months post-intervention for participants with hypertension (i.e., for each arm). |
| Controlled Systolic Blood Pressure (<140mmHg), 9-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | 9-months post-intervention for participants with hypertension (i.e., for each arm). |
| Controlled Systolic Blood Pressure (<140mmHg), 12-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | 12-months post-intervention for participants with hypertension (i.e., for each arm). |
| WHO Staging, 3 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | 3 months post-intervention for all participants (i.e., for each arm) |
| WHO Staging, 6 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | 6 months post-intervention for all participants (i.e., for each arm) |
| WHO Staging, 9 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | 9 months post-intervention for all participants (i.e., for each arm) |
| WHO Staging, 12 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | 12 months post-intervention for all participants (i.e., for each arm) |
| Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 3 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | 3 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
| Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 6 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | 6 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
| Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 9 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | 9 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
| Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 12 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | 12 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
| Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 3 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | 3 months post-intervention for all participants with epilepsy (i.e., for each arm) |
| Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 6 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | 6 months post-intervention for all participants with epilepsy (i.e., for each arm) |
| Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 9 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | 9 months post-intervention for all participants with epilepsy (i.e., for each arm) |
| Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 12 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | 12 months post-intervention for all participants with epilepsy (i.e., for each arm) |
| 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
| Prevalence of Depression (PHQ-9 Score > 9) Among Household Members, 6 Months After the Start of Study Participant Treatment Eligibility | Prevalence of depression is calculated as the number of household participants with a PHQ-9 score of 9 or greater at the time of measurement. | 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
| Functional Impairment (WHO Disability Assessment Schedule) Among Household Members, 6 Months After the Start of Study Participant Treatment Eligibility | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS) among household members. This will be quantified as WHODAS score at 6 months after the start of study participant treatment eligibility. It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
| Overall Health Profile (EQ-5D-5L) Among Household Members, 6 Months After the Start of Study Participant Treatment Eligibility | A health profile will be generated for each household member using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 6-months after the start of study participants' treatment eligibility. It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
| Perceived Social Support (MSPSS), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 3-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | 3 months post-intervention for all participants (i.e., for each arm) |
| Perceived Social Support (MSPSS), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 6-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | 6 months post-intervention for all participants (i.e., for each arm) |
| Perceived Social Support (MSPSS), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 9-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | 9 months post-intervention for all participants (i.e., for each arm) |
| Perceived Social Support (MSPSS), 12 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 12-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | 12 months post-intervention for all participants (i.e., for each arm) |
| Internalized Mental Health Stigma (ISMI), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 3-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 3 months post-intervention for all participants (i.e., for each arm) |
| Internalized Mental Health Stigma (ISMI), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 6-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 6 months post-intervention for all participants (i.e., for each arm) |
| Internalized Mental Health Stigma (ISMI), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 9-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 9 months post-intervention for all participants (i.e., for each arm) |
| Internalized Mental Health Stigma (ISMI), 12 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 12-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 12 months post-intervention for all participants (i.e., for each arm) |
| AIDS-related Stigma (ARSS), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 3-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 3 months post-intervention for all participants (i.e., for each arm) |
| AIDS-related Stigma (ARSS), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 6-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 6 months post-intervention for all participants (i.e., for each arm) |
| AIDS-related Stigma (ARSS), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 9-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 9 months post-intervention for all participants (i.e., for each arm) |
| AIDS-related Stigma (ARSS), 12 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 12-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | 12 months post-intervention for all participants (i.e., for each arm) |
| Background |
| Passchier RV, Abas MA, Ebuenyi ID, Pariante CM. Effectiveness of depression interventions for people living with HIV in Sub-Saharan Africa: A systematic review & meta-analysis of psychological & immunological outcomes. Brain Behav Immun. 2018 Oct;73:261-273. doi: 10.1016/j.bbi.2018.05.010. Epub 2018 May 13. |
| 26668435 | Background | McBain RK, Salhi C, Hann K, Kellie J, Kamara A, Salomon JA, Kim JJ, Betancourt TS. Improving outcomes for caregivers through treatment of young people affected by war: a randomized controlled trial in Sierra Leone. Bull World Health Organ. 2015 Dec 1;93(12):834-41. doi: 10.2471/BLT.14.139105. Epub 2015 Oct 16. |
| 26407793 | Background | Dawson KS, Bryant RA, Harper M, Kuowei Tay A, Rahman A, Schafer A, van Ommeren M. Problem Management Plus (PM+): a WHO transdiagnostic psychological intervention for common mental health problems. World Psychiatry. 2015 Oct;14(3):354-7. doi: 10.1002/wps.20255. No abstract available. |
| 11556941 | Background | Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13. doi: 10.1046/j.1525-1497.2001.016009606.x. |
| 41372945 | Derived | Kamwiyo M, Mwale O, Mpinga K, Kayira W, Johnson I, Ruderman T, Matanje B, Kasambara K, Houde A, Isaacs R, Needham C, Wagner G, Kulisewa K, Udedi M, McBain RK. Provider perceptions and experiences integrating depression treatment into chronic healthcare services in Neno District, Malawi: a qualitative study. BMC Health Serv Res. 2025 Dec 10;26(1):66. doi: 10.1186/s12913-025-13830-2. |
| 41062145 | Derived | Mwale O, Mpinga K, Rukundo T, Kamwiyo M, Kayira W, Matanje B, Munyaneza F, Ruderman T, Raviola G, Smith S, Okunogbe A, Kachimanga C, McBain RK. Cost analysis of integrating depression treatment into chronic care in Malawi: evidence from a cluster randomised controlled trial. BMJ Open. 2025 Oct 7;15(10):e095494. doi: 10.1136/bmjopen-2024-095494. |
| 40340587 | Derived | Mwale O, Kasambala C, Houde A, Mpinga K, Kayira W, Harawa M, Kamwiyo M, Isaacs R, Nhlema B, Ruderman T, Liwimbi O, Udedi M, Kelly K, McBain RK. Patient perspectives on group problem management plus for adults with major depressive disorder in rural Malawi. Glob Health Action. 2025 Dec;18(1):2500785. doi: 10.1080/16549716.2025.2500785. Epub 2025 May 9. |
| 39488229 | Derived | McBain RK, Mwale O, Mpinga K, Kamwiyo M, Kayira W, Ruderman T, Connolly E, Watson SI, Wroe EB, Munyaneza F, Dullie L, Raviola G, Smith SL, Kulisewa K, Udedi M, Patel V, Wagner GJ. Effectiveness, cost-effectiveness, and positive externalities of integrated chronic care for adults with major depressive disorder in Malawi (IC3D): a stepped-wedge, cluster-randomised, controlled trial. Lancet. 2024 Nov 9;404(10465):1823-1834. doi: 10.1016/S0140-6736(24)01809-9. Epub 2024 Oct 30. |
| 37554074 | Derived | Mpinga K, Rukundo T, Mwale O, Kamwiyo M, Thengo L, Ruderman T, Matanje B, Munyaneza F, Connolly E, Kulisewa K, Udedi M, Kachimanga C, Dullie L, McBain R. Depressive disorder at the household level: prevalence and correlates of depressive symptoms among household members. Glob Health Action. 2023 Dec 31;16(1):2241808. doi: 10.1080/16549716.2023.2241808. |
| 37001058 | Derived | Mpinga K, Lee SD, Mwale O, Kamwiyo M, Nyirongo R, Ruderman T, Connolly E, Kayira W, Munyaneza F, Matanje B, Kachimanga C, Zaniku HR, Kulisewa K, Udedi M, Wagner G, McBain R. Prevalence and correlates of internalized stigma among adults with HIV and major depressive disorder in rural Malawi. AIDS Care. 2023 Nov;35(11):1775-1785. doi: 10.1080/09540121.2023.2195609. Epub 2023 Mar 31. |
| 34530894 | Derived | McBain RK, Mwale O, Ruderman T, Kayira W, Connolly E, Chalamanda M, Kachimanga C, Khongo BD, Wilson J, Wroe E, Raviola G, Smith S, Coleman S, Kelly K, Houde A, Tebeka MG, Watson S, Kulisewa K, Udedi M, Wagner G. Stepped care for depression at integrated chronic care centers (IC3) in Malawi: study protocol for a stepped-wedge cluster randomized controlled trial. Trials. 2021 Sep 16;22(1):630. doi: 10.1186/s13063-021-05601-1. |
| BG001 | Cluster 2 (Second Cluster of Clinics Randomized to Receive Care) | Arm 2 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 6 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| BG002 | Cluster 3 (Third Cluster of Clinics Randomized to Receive Care) | Arm 3 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 9 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| BG003 | Cluster 4 (Fourth Cluster of Clinics Randomized to Receive Care) | Arm 4 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 12 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| BG004 | Cluster 5 (Fifth Cluster of Clinics Randomized to Receive Care) | Arm 5 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 15 of the trial Problem Management Plus: PM+ is a cognitive-behavioral intervention that trains recipients to improve their management of practical problems. Antidepressant Therapy: Fluoxetine, a serotonin selective reuptake inhibitor (SSRI), and amitriptyline, a tricyclic antidepressant (TCA), are part of Malawi's national formulary. Neno District supply chain is supported by PIH, which reduces stock-outs relative to those observed in other Malawian settings. Fluoxetine is typically the first drug of choice because it is safer and better tolerated. Daily dose will commence at 20 mg of fluoxetine, or 25 mg of amitriptyline. At monthly follow-up visits, a dose increment or medication change may be considered based on measures of treatment response and side effects, using an Antidepressant Side Effect Checklist. This algorithm-based process will be repeated every other week until the patient is fully responding to treatment (PHQ-9 < 5) for a period of three months. Dose escalations of more than one increment and medication changes will be reviewed with the doctor-in-charge. If on ADT at end of study, it will be sustained as part of usual care. |
| BG005 | Total | Total of all reporting groups |
| years |
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| Sex: Female, Male | Count of Participants | Participants |
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| Race (NIH/OMB) | Count of Participants | Participants |
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| Region of Enrollment | Count of Participants | Participants |
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| OG001 | Cluster 2 (Second Cluster of Clinics Randomized to Receive Care) | Arm 2 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 6 of the trial |
| OG002 | Cluster 3 (Third Cluster of Clinics Randomized to Receive Care) | Arm 3 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 9 of the trial |
| OG003 | Cluster 4 (Fourth Cluster of Clinics Randomized to Receive Care) | Arm 4 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 12 of the trial |
| OG004 | Cluster 5 (Fifth Cluster of Clinics Randomized to Receive Care) | Arm 5 represents a cluster of 2-3 clinics randomized to begin delivering the intervention at month 15 of the trial |
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| Primary | Depression Symptoms (PHQ-9), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 6-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 6 months post-intervention for all participants (i.e., for each arm) |
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| Primary | Depression Symptoms (PHQ-9), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 9-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 9 months post-intervention for all participants (i.e., for each arm) |
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| Primary | Depression Symptoms (PHQ-9), 12 Months Post-intervention for All Participants (i.e., for Each Arm). | Depression symptoms will be measured with the Patient Health Questionnaire 9 (PHQ-9). This will be quantified as PHQ-9 score at 12-months (post-intervention). It is not a change score. Scale Name: Patient Health Questionnaire - 9 Scale Range (Min-Max): 0-27 Scale Notes: Higher value is considered more severe depression symptoms. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 12 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Functional Impairment (WHO Disability Assessment Schedule), 3 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 3-months (post-intervention). It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 3 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Functional Impairment (WHO Disability Assessment Schedule), 6 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 6-months (post-intervention). It is not a change score. Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 6 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Functional Impairment (WHO Disability Assessment Schedule), 9 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 9-months (post-intervention). It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 9 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Functional Impairment (WHO Disability Assessment Schedule), 12 Months Post-intervention for All Participants (i.e., for Each Arm). | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS). This will be quantified as WHODAS score at 12-months (post-intervention). It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 12 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Overall Health Profile (EQ-5D-5L), 3 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 3-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 3 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Overall Health Profile (EQ-5D-5L), 6 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 6-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 6 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Overall Health Profile, 9 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 9-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 9 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Overall Health Profile, 12 Months Post-intervention for All Participants (i.e., for Each Arm). | A health profile will be generated for each individual using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 12-months (post-intervention). It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 12 months post-intervention for all participants (i.e., for each arm). |
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| Primary | Prevalence of Depression (PHQ-9 Score > 9), 3-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | Posted | Number | participants | 3 months post-intervention for all participants (for each arm). |
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| Primary | Prevalence of Depression (PHQ-9 Score > 9), 6-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | Prevalence of depression is calculated as the number participants with a PHQ-9 score of 9 or greater at the time of measurement. | Posted | Count of Participants | Participants | 6 months post-intervention for all participants (for each arm). |
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| Primary | Prevalence of Depression (PHQ-9 Score > 9), 9-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | Posted | Count of Participants | Participants | 9 months post-intervention for all participants (for each arm). |
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| Primary | Prevalence of Depression (PHQ-9 Score > 9), 12-months Post-intervention for All Participants (for Each Arm). | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | Prevalence of depression is calculated as the number of participants with a PHQ-9 score of 9 or greater at the time of measurement. | Posted | Count of Participants | Participants | 12 months post-intervention for all participants (for each arm). |
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| Secondary | ART Adherence (Medication Pick-Up Every 3 Months), 3-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | Posted | Count of Participants | Participants | 3 months post-intervention for participants with HIV (i.e., for each arm). |
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| Secondary | ART Adherence (Medication Pick-Up Every 3 Months), 6-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | Posted | Count of Participants | Participants | 6 months post-intervention for participants with HIV (i.e., for each arm). |
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| Secondary | ART Adherence (Medication Pick-Up Every 3 Months), 9-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | Posted | Count of Participants | Participants | 9 months post-intervention for participants with HIV (i.e., for each arm). |
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| Secondary | ART Adherence (Medication Pick-Up Every 3 Months), 12-Months Post-Intervention for Participants With HIV (for Each Arm) | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | ART adherence will be measured in terms of whether patients with HIV have returned to their health clinic for antiretrovirals (ARVs) within the prior three months for quarterly medication pick-up, consistent with national guidelines. Adherence is calculated as the number who satisfy this criterion out of those who are eligible. | Posted | Count of Participants | Participants | 12 months post-intervention for participants with HIV (i.e., for each arm) |
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| Secondary | Viral Suppression (<500 Copies of the Virus Per mL of Blood), 3-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Posted | Count of Participants | Participants | 3-months post-intervention for participants with HIV (i.e., for each arm). |
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| Secondary | Viral Suppression (<500 Copies of the Virus Per mL of Blood), 6-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Posted | Count of Participants | Participants | 6-months post-intervention for participants with HIV (i.e., for each arm). |
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| Secondary | Viral Suppression (<500 Copies of the Virus Per mL of Blood), 9-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Posted | Count of Participants | Participants | 9-months post-intervention for participants with HIV (i.e., for each arm). |
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| Secondary | Viral Suppression (<500 Copies of the Virus Per mL of Blood), 12-Months Post-Intervention for Participants With HIV (for Each Arm) | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Viral suppression will be measured in terms of whether patients with HIV been measured in the previous three months and reported <500 copies of the virus per mL of blood, consistent with national guidelines. Viral suppression is calculated as the number who satisfy this criterion out of those who are eligible (i.e., viral load measured in the prior three months). | Posted | Count of Participants | Participants | 12-months post-intervention for participants with HIV (i.e., for each arm). |
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| Secondary | Controlled Systolic Blood Pressure (<140mmHg), 3-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Posted | Count of Participants | Participants | 3 months post-intervention for participants with hypertension (i.e., for each arm). |
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| Secondary | Controlled Systolic Blood Pressure (<140mmHg), 6-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Posted | Count of Participants | Participants | 6 months post-intervention for participants with hypertension (i.e., for each arm). |
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| Secondary | Controlled Systolic Blood Pressure (<140mmHg), 9-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Posted | Count of Participants | Participants | 9-months post-intervention for participants with hypertension (i.e., for each arm). |
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| Secondary | Controlled Systolic Blood Pressure (<140mmHg), 12-Months Post-Intervention for Participants With Hypertension (for Each Arm) | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Controlled blood pressure will be measured in terms of whether patients with hypertension been measured in the previous three months and reported systolic blood pressure <140 mmHg, consistent with national guidelines. Controlled blood pressure is calculated as the number who satisfy this criterion out of those who are eligible (i.e., systolic blood pressure measured in the prior three months, among hypertension patients). | Posted | Count of Participants | Participants | 12-months post-intervention for participants with hypertension (i.e., for each arm). |
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| Secondary | WHO Staging, 3 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | Partners In Health (the implementation partner on the grant) did not collect WHO staging over the grant period. PIH has ceased routinely collecting WHO staging, as health facilities now have much more sensitive markers: viral load and CD4 count measures. This is consistent with national guidelines in Malawi. | Posted | 3 months post-intervention for all participants (i.e., for each arm) |
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| Secondary | WHO Staging, 6 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | Partners In Health (the implementation partner on the grant) did not collect WHO staging over the grant period; therefore, the number participants analyzed was 0. PIH has ceased routinely collecting WHO staging, as health facilities now have much more sensitive markers: viral load and CD4 count measures. This is consistent with national guidelines in Malawi. | Posted | 6 months post-intervention for all participants (i.e., for each arm) |
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| Secondary | WHO Staging, 9 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | Partners In Health (the implementation partner on the grant) did not collect WHO staging over the grant period; therefore, the number participants analyzed was 0. PIH has ceased routinely collecting WHO staging, as health facilities now have much more sensitive markers: viral load and CD4 count measures. This is consistent with national guidelines in Malawi. | Posted | 9 months post-intervention for all participants (i.e., for each arm) |
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| Secondary | WHO Staging, 12 Months Post-intervention for All Participants (i.e., for Each Arm) | WHO staging will be measured the World Health Organization's clinical staging system for HIV/AIDS, which classifies disease progression based on the presence of specific clinical conditions and symptoms, ranging from Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses). Instrument Name: WHO's Clinical Staging System for HIV/AIDS Instrument Range: Stage I (asymptomatic) to Stage IV (AIDS-defining illnesses) Instrument Notes: Higher stage considered more severe progression of illness. There are no combined subscales. | Partners In Health (the implementation partner on the grant) did not collect WHO staging over the grant period; therefore, the number participants analyzed was 0. PIH has ceased routinely collecting WHO staging, as health facilities now have much more sensitive markers: viral load and CD4 count measures. This is consistent with national guidelines in Malawi. | Posted | 12 months post-intervention for all participants (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 3 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | No participants were analyzed for this outcome because no HbA1c laboratory values were available for participants with type 2 diabetes. Although some diabetes-related information and blood glucose measurements were collected, blood glucose is not equivalent to HbA1c and was not the pre-specified metric. Due to supply chain difficulties over the course of COVID-19, the implementation partner (PIH) was unable to store HbA1C samples in cold supply chain. | Posted | 3 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 6 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | No participants were analyzed for this outcome because no HbA1c laboratory values were available for participants with type 2 diabetes. Although some diabetes-related information and blood glucose measurements were collected, blood glucose is not equivalent to HbA1c and was not the pre-specified metric. Due to supply chain difficulties over the course of COVID-19, the implementation partner (PIH) was unable to store HbA1C samples in cold supply chain. | Posted | 6 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 9 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | No participants were analyzed for this outcome because no HbA1c laboratory values were available for participants with type 2 diabetes. Although some diabetes-related information and blood glucose measurements were collected, blood glucose is not equivalent to HbA1c and was not the pre-specified metric. Due to supply chain difficulties over the course of COVID-19, the implementation partner (PIH) was unable to store HbA1C samples in cold supply chain. | Posted | 9 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Type II Diabetes With Controlled Diabetes (HbA1C Below 8.0%), 12 Months Post-intervention (i.e., for Each Arm) | HbA1C measurement will be measured using a laboratory-based immunoassay or high-performance liquid chromatography (HPLC) method, standardized to the National Glycohemoglobin Standardization Program (NGSP) and traceable to the Diabetes Control and Complications Trial (DCCT) reference, in accordance with international guidelines. Diabetes control was defined as an HbA1c level below 8.0%, consistent with WHO and ADA-recommended thresholds for glycemic control in resource-limited settings and among patients with comorbidities or limited life expectancy. Our primary outcome was the proportion of patients with type 2 diabetes achieving this target. | No participants were analyzed for this outcome because no HbA1c laboratory values were available for participants with type 2 diabetes. Although some diabetes-related information and blood glucose measurements were collected, blood glucose is not equivalent to HbA1c and was not the pre-specified metric. Due to supply chain difficulties over the course of COVID-19, the implementation partner (PIH) was unable to store HbA1C samples in cold supply chain. | Posted | 12 months post-intervention for all participants with type-2 diabetes (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 3 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | Number of participants reporting seizures in the prior 3 months | Posted | Count of Participants | Participants | 3 months post-intervention for all participants with epilepsy (i.e., for each arm) |
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| Other Pre-specified | Perceived Burden of Care (BAS) Among Household Member, 6 Months After the Start of Study Participant Treatment Eligibility | Perceived burden of care will be measured according to the Burden Assessment Schedule (BAS). This will be quantified as household member's score at 6-months after initiation of treatment eligibility for the study trial participant. Scale Name: Burden Assessment Schedule Scale Range (Min-Max): 0-57 Scale Notes: Higher value indicates more severe perceived burden of care. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
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| Other Pre-specified | Prevalence of Depression (PHQ-9 Score > 9) Among Household Members, 6 Months After the Start of Study Participant Treatment Eligibility | Prevalence of depression is calculated as the number of household participants with a PHQ-9 score of 9 or greater at the time of measurement. | Posted | Count of Participants | Participants | 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
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| Other Pre-specified | Functional Impairment (WHO Disability Assessment Schedule) Among Household Members, 6 Months After the Start of Study Participant Treatment Eligibility | Functional impairment will be measured with the World Health Organization (WHO) Disability Assessment Schedule (WHODAS) among household members. This will be quantified as WHODAS score at 6 months after the start of study participant treatment eligibility. It is not a change score. Scale Name: WHO Disability Assessment Schedule Scale Range (Min-Max): 12-60 Scale Notes: Higher value is considered more severe functional impairment. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
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| Other Pre-specified | Overall Health Profile (EQ-5D-5L) Among Household Members, 6 Months After the Start of Study Participant Treatment Eligibility | A health profile will be generated for each household member using the EuroQol (EQ-5D-5L). This will be quantified as EQ-5D-5L score at 6-months after the start of study participants' treatment eligibility. It is not a change score. Scale Name: EuroQol, EQ-5D-5L Scale Range (Min-Max): 5-25 Scale Notes: Higher value is considered worse overall health. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 6-months after initiation of treatment eligibility for the study trial participant (for each arm). |
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| Other Pre-specified | Perceived Social Support (MSPSS), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 3-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | Posted | Mean | Standard Deviation | score on a scale | 3 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | Perceived Social Support (MSPSS), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 6-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | The outcome at 6 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 6 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | Perceived Social Support (MSPSS), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 9-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | The outcome at 9 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | units on a scale | 9 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | Perceived Social Support (MSPSS), 12 Months Post-intervention for All Participants (i.e., for Each Arm) | Perceived social support will be measured with the Multidimensional Scale of Perceived Social Support (MSPSS). This will be quantified as MSPSS score at 12-months (post-intervention). It is not a change score. Scale Name: Multidimensional Scale of Perceived Social Support Scale Range (Min-Max): 12-84 Scale Notes: Higher value is considered greater social support. There are no combined subscales. | The outcome at 12 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 12 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | Internalized Mental Health Stigma (ISMI), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 3-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 3 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 3 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | Internalized Mental Health Stigma (ISMI), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 6-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 6 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 6 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | Internalized Mental Health Stigma (ISMI), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 9-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 9 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 9 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | Internalized Mental Health Stigma (ISMI), 12 Months Post-intervention for All Participants (i.e., for Each Arm) | Internalized mental health stigma will be measured with the Internalized Stigma of Mental Illness Scale (ISMI). This will be quantified as ISMI score at 12-months (post-intervention). It is not a change score. Scale Name: Internalized Stigma of Mental Illness Scale Scale Range (Min-Max): 10-40 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 12 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 12 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | AIDS-related Stigma (ARSS), 3 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 3-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 3 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 3 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | AIDS-related Stigma (ARSS), 6 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 6-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 6 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 6 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | AIDS-related Stigma (ARSS), 9 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 9-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 9 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 9 months post-intervention for all participants (i.e., for each arm) |
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| Other Pre-specified | AIDS-related Stigma (ARSS), 12 Months Post-intervention for All Participants (i.e., for Each Arm) | AIDS-related stigma will be measured with the AIDS-Related Stigma Scale (ARSS). This will be quantified as ARSS score at 12-months (post-intervention). It is not a change score. Scale Name: AIDS-Related Stigma Scale Scale Range (Min-Max): 0-6 Scale Notes: Higher value is considered greater internalized stigma. There are no combined subscales. | The outcome at 12 months post-intervention is reported as descriptive data for all participants (i.e., for each arm). | Posted | Mean | Standard Deviation | score on a scale | 12 months post-intervention for all participants (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 6 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | Number of participants reporting seizures in the prior 3 months | Posted | Count of Participants | Participants | 6 months post-intervention for all participants with epilepsy (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 9 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | Number of participants reporting seizures in the prior 3 months | Posted | Count of Participants | Participants | 9 months post-intervention for all participants with epilepsy (i.e., for each arm) |
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| Secondary | Proportion of Study Participants With Epilepsy Reporting Seizures in the Prior 3 Months, 12 Months Post-intervention (i.e., for Each Arm) | Any seizures (yes/no) in the prior three months was self-reported among participants with diagnosed epilepsy. | Number of participants reporting seizures in the prior 3 months | Posted | Count of Participants | Participants | 12 months post-intervention for all participants with epilepsy (i.e., for each arm) |
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| 2 |
| 97 |
| 0 |
| 97 |
| 0 |
| 97 |
| EG001 | Cluster 2 (Second Cluster of Clinics Randomized to Receive Care) | Arm 2 represents a cluster of 2-3 clinics randomized to begin delivering the intervention | 3 | 175 | 0 | 175 | 0 | 175 |
| EG002 | Cluster 3 (Third Cluster of Clinics Randomized to Receive Care) | Arm 3 represents a cluster of 2-3 clinics randomized to begin delivering the intervention | 1 | 64 | 0 | 64 | 0 | 64 |
| EG003 | Cluster 4 (Fourth Cluster of Clinics Randomized to Receive Care) | Arm 4 represents a cluster of 2-3 clinics randomized to begin delivering the intervention | 2 | 86 | 0 | 86 | 0 | 86 |
| EG004 | Cluster 5 (Fifth Cluster of Clinics Randomized to Receive Care) | Arm 5 represents a cluster of 2-3 clinics randomized to begin delivering the intervention | 1 | 65 | 0 | 65 | 0 | 65 |
Not provided
Not provided
| D001567 |
| Benzocycloheptenes |
| D011084 | Polycyclic Aromatic Hydrocarbons |
| D006841 | Hydrocarbons, Aromatic |
| D006844 | Hydrocarbons, Cyclic |
| D006838 | Hydrocarbons |
| D011083 | Polycyclic Compounds |