Community-based ‘grandmothers’ could empower people living with HIV to take their medication

People living with HIV alongside common mental health disorders may be three times more likely to maintain a low level of virus through medication if supported with therapy through the Friendship Bench project, according to new study results.

The study, run in Zimbabwe, is the first of its kind to assess whether community-based therapy through the Friendship Bench project could improve outcomes for those living with long-term illness alongside a mental health disorder. The study is published in the journal PLOS Global Public Health.

The Friendship Bench initiative, founded by Dr. Dixon Chibanda, professor of psychiatry and global mental health at the London School of Hygiene & Tropical Medicine (LSHTM), uses a community-based approach to provide therapy to people living with mental health disorders.

Wooden park benches are placed in discreet areas near to health clinics and each attendee receives up to six one-to-one counseling sessions. The sessions are delivered by older community volunteers, known as “grandmothers,” who do not have prior medical knowledge but receive training in problem-solving therapy through the initiative.

For people living with HIV, taking antiretroviral therapy (ART) as prescribed can decrease and maintain a lower level of virus within the body. Sustaining a low viral load is a key goal in HIV care, as it can halt progression to AIDS, enable near-normal life expectancy and decrease the risk of onward transmission to sexual partners, including that of drug-resistant strains.

Among the most common comorbidities recorded for people living with HIV are mental health disorders such as depression or anxiety. Previous research has shown that patients living with both conditions may be less likely to adhere to ART.

The study led by researchers from LSHTM, King’s College London and the University of Zimbabwe, recruited 700 participants aged 18 and over across eight HIV care clinics in Harare. Patients at six of the clinics received therapy through the Friendship Bench program, while those at the remaining two clinics received usual care. Blood tests to measure viral load and mental health assessments were taken at the start of the study and followed-up after six months of treatment.

Of the 499 patients who already had a suppressed level of virus at the start of the study, those who received therapy through the Friendship Bench were three times less likely for their viral load to increase above the clinical threshold for suppression, which would prevent sexual transmission of the virus to a HIV-negative partner, compared with those who received usual care (2.9% vs. 9.3%).

Out of all participants in the study, those who attended the Friendship Bench clinics were also six times less likely to screen for a common mental health disorder at the end of the study (-36.5% vs. -6.7%), emphasizing the importance of incorporating mental health support into HIV care.

The team are now looking to replicate these findings with a larger cohort and follow patients over a longer period of time. Studies to assess whether the project can support outcomes for people living with common mental health disorders alongside other chronic illnesses, such as diabetes or hypertension, are ongoing.

Dr. Dixon Chibanda said, “The world is in the grips of a mental health crisis. People living with common mental disorders, including those who also need support to manage a long-term condition, are desperately seeking help but don’t know where to turn.

“In an ideal situation, every patient needing psychiatric care would have access to one-on-one therapy with a trained doctor. Unfortunately, even wealthier health systems lack the capacity to offer such services as widely as is needed. The Friendship Bench offers an opportunity to fill this void and to reach patients within the heart of their own communities.”

Professor Melanie Abas, joint first author and professor of global mental health at King’s College London, said, “Living with HIV is very challenging and can have a potentially devastating impact on a person’s mental well-being. Our study establishes that the simple act of receiving basic problem-solving therapy from a lay counselor in a community setting can positively influence viral suppression and low mood.

“This benefit was most pronounced for people with depression whose adherence to HIV medication was already good. For people with depression and poor adherence to HIV medication, the Friendship Bench was able to help with low mood but could not get them back on track with adherence and viral suppression.

“It’s vital now that we follow up this research to establish how to improve counseling to optimize HIV disease control. This is what our new trial is testing.”

The Friendship Bench program has been running for over 10 years in Zimbabwe and has been shown to significantly improve the symptoms of patients with common mental health disorders. It has now been successfully scaled up to all 10 provinces, covering a total population of approximately 16 million. In 2023, over 2000 community health workers helped deliver therapy for over 300,000 people living across the country.

Since its inception, Friendship Benches have also been replicated in other parts of the world including New York, Washington DC, Vietnam and Jordan thanks to funders including the philanthropist MacKenzie Scott and the Mulago Foundation.

Dr. Chibanda and team are also exploring a pilot Friendship Bench in London and testing an enhanced form of the Friendship Bench called TENDAI, in people with depression and poorly controlled HIV.