Participant Acceptability and Clinician Satisfaction of Cognitive Behavioral Therapy and a Medication Management Algorithm Compared with Enhanced Standard Care for Treatment of Depression among Youth Living with HIV


BACKGROUND: Primary results of the International Maternal Pediatric Adolescent AIDS Clinical Trials Network (IMPAACT) 2002 trial showed that a Cognitive Behavioral Therapy (CBT) and Medication Management Algorithm (MMA) (COMB-R) significantly improved depression outcomes in Youth Living with HIV (YLWH) compared with Enhanced Standard Care (ESC). Because participant perspectives and experiences of CBT are an important complement to treatment efficacy (Olsson, JBCT, 2021), we examined and compared the acceptability and satisfaction of these approaches among study participants and clinicians.
METHODS: Between March 2017 and March 2019, 13 U.S. sites enrolled YLWH, ages 12-24, diagnosed with nonpsychotic depression. Using restricted randomization to balance site characteristics, sites were randomized to either COMB-R (CBT administered by a therapist and a licensed prescriber trained in the MMA) or ESC (standard psychotherapy and medication management). After intervention conclusion at Week 24, participants and clinicians (licensed prescribers and therapists) rated their acceptability and satisfaction of the treatment in multi-question surveys, with higher ratings indicating more desirable outcomes. Site-level means were compared using Wilcoxon tests.
RESULTS: Overall, 69 participants were in COMB-R and 71 were in ESC. The mean age was 21.4 years, 53% were female, and 54% were living with perinatally acquired HIV. Baseline age, sex, depression levels, RNA viral load, and CD4 count were similar between groups. The distribution of site-level mean participant acceptability (quality, expectations, and overall satisfaction with treatment) was greater in COMB-R compared with ESC (Table 1). The distribution of site-level mean licensed prescriber satisfaction (ease of using the intervention and improvement of participants' symptoms) was also greater in COMB-R compared with ESC. The distribution of site-level mean therapist satisfaction did not differ between groups.

Table 1. Median (Minimum, Maximum) of site-level mean participant acceptability and clinician satisfaction
SurveySurvey DescriptionCOMB-R
(6 sites)
(7 sites)
(Wilcoxon Test)
Participant acceptability8 questions; scale from 1 to 4
3.7 (3.5, 3.9)
3.4 (3.3, 3.7)
Prescribing clinician satisfaction2 questions; scale from 0 to 4
3.2 (2.5, 3.4)
2.4 (2.0, 3.0)
Counseling clinician satisfaction6 questions; scale from 0 to 3
2.1 (1.9, 2.8)
2.3 (2.0, 2.6)

CONCLUSIONS: We found that mean acceptability and satisfaction for participants and licensed prescribers were significantly higher at COMB-R sites compared with ESC sites. These results further support the use of CBT and MMA in treating depression among YLWH.

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