The Effects Of Group Support Psychotherapy Delivered By Lay Health Workers On Depression Among Persons Living With HIV In Northern Uganda

Principal investigator: Etheldreda Nakimuli-Mpungu

Institution: Makerere University

Location: Uganda

Research award: Fellows Award

Funding Period: 2016-2019

Can HIV health workers in rural Uganda be trained to treat the mental health of their patients as well as the physical?

The project

Finding effective treatment for depression in rural northern Uganda is anything but easy.

But health workers do visit isolated communities to care for people who live with HIV. So Etheldreda is training those health workers to recognise and respond to depression too – by delivering group psychotherapy.

Etheldreda and her team aimed to assess the effects of group support psychotherapy (GSP) delivered by lay health workers (LHWs) on depression among people living with HIV in rural Northern Uganda. The intervention sought to address the high prevalence of depression in this population, where access to recommended treatments is limited. The project was conducted as a cluster randomised clinical trial, comparing GSP with group HIV education (GHE) as a control.

The process

By working within existing health systems, Etheldreda is bringing depression therapies to areas that would otherwise have been unreachable.

Community Engagement: The team conducted community sensitisation meetings and formed advisory boards in each target district. They assessed the training needs of LHWs and their perceptions towards depression treatment;
Training: LHWs were trained in GSP using a train-the-trainer model. Over 150 LHWs were trained, who then delivered interventions to more than 1,400 HIV-infected adults with mild-moderate depression;
Implementation: The intervention was rolled out in village health facilities, with LHWs delivering either GSP or GHE. Data collection included baseline, post-intervention, and follow-up assessments at 6, 12, 18, and 24 months;
Evaluation: The project included process evaluation, cost-effectiveness analysis, and ongoing qualitative interviews with stakeholders, LHWs, and participants. Ethical oversight was maintained throughout, with adjustments made following recommendations from ethics boards.

The outcome

As Uganda continues to rebuild following years of conflict, this project is helping people who live with depression to access treatment that otherwise wouldn’t have been available.

Clinical Effectiveness: GSP led to greater reductions in depression scores, improved functioning, lower suicide risk, and better HIV treatment outcomes compared to GHE. These effects were sustained and even increased at 12 months post-intervention;
Secondary Outcomes: Participants in the GSP group reported improved food security, increased income-generating activities, reduced PTSD symptoms, and improved self-esteem. There was also better adherence to antiretroviral therapy (ART) and reduced HIV-related stigma;
Cost-Effectiveness: GSP was found to be highly cost-effective, with an incremental cost-effectiveness ratio well below WHO thresholds. Reliance on LHWs contributed to the sustainability and affordability of the intervention;
Adverse Events: Suicide risk was monitored, with some adverse events occurring in both arms. The project responded with referrals and additional support for those at risk.

Papers published

Nakimuli-Mpungu E, Musisi S, Wamala K, Okello J, Ndyanabangi S, Mojtabai R, Nachega J, Harari O, Mills E. The Effect of Group Support Psychotherapy Delivered by Trained Lay Health Workers for Depression Treatment Among People with HIV in Uganda: Protocol of a Pragmatic, Cluster Randomized Trial. JMIR Res Protoc. 2017
Nakimuli-Mpungu E, Musisi S, Wamala K, Okello J, Ndyanabangi S, Birungi J, Nanfuka M, Etukoit M, Mojtabai R, Nachega J, Harari O, Mills E. Recruitment and Baseline Characteristics of Participants in the Social, Emotional, and Economic Empowerment Through Knowledge of Group Support Psychotherapy Study (SEEK-GSP): Cluster Randomized Controlled Trial. JMIR Res Protoc. 2019
Nakimuli-Mpungu E, Musisi S, Wamala K, Okello J, Ndyanabangi S, Birungi J, Nanfuka M, Etukoit M, Mayora C, Ssengooba F, Mojtabai R, Nachega JB, Harari O, Mills EJ. Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster-randomised trial. Lancet Glob Health. 2020
Nakimuli-Mpungu Etheldreda , Wamala Kizito , Nalugya Joyce Sserunjoji , Nakanyike Caroline , Iya Jane , Bakeera Kitaka Sabrina , Diana Namuli Justine , Akimana Benedict , Nachega Jean B. , Mills Edward J. , Seggane Musisi. The effect of group support psychotherapy on adherence to anti-retroviral therapy and viral suppression among HIV positive young people: Study protocol for a pilot randomized controlled trial. Frontiers in Health Services. 2023

In 2020 Etheldreda was named one of the BBC’s 100 most influential women in the world as a result of her MQ-funded research. She also received several prestigious awards, including the Elsevier Foundation Award for Early Career Women Scientists and the Ugandan Presidential National Independence Medal of Honor.

“For me, being an MQ fellow gave me visibility in local communities, nationally and internationally. For my career development Prior to the MQ award, I had acquired research skills from my PhD training at Johns Hopkins University and had gain some research field experience. But without any significant funding, I felt like I was all dressed up with nowhere to go. Winning the MQ award gave my research career a new lease on life.” Ethel Nakimuli-Mpungu

The impact

You can read more about the impact of this project in this blog.

The project demonstrated that group support psychotherapy (GSP), delivered by lay health workers (LHWs), can dramatically reduce depression among people living with HIV in rural Uganda. This is a population with limited access to mental health services, and the intervention provided a scalable, culturally sensitive solution.

Improved Clinical and Social Outcomes

Mental Health: Participants receiving GSP showed greater reductions in depression scores, lower suicide risk, and improved functioning compared to those receiving group HIV education (GHE). These improvements were sustained and even increased at 12 months post-intervention;
HIV Outcomes: The GSP group had better adherence to antiretroviral therapy (ART) and fewer detectable viral loads, indicating improved HIV treatment outcomes. There was also less HIV-related stigma and fewer people leaving treatment;
Social and Economic Empowerment: GSP participants reported improved food security, increased participation in income-generating activities, and improved self-esteem. Success stories include groups starting farming projects, purchasing oxen, and generating income, which helped them meet basic needs such as food and school fees for their children.

Cost-Effectiveness and Sustainability

The intervention was found to be highly cost-effective, with an incremental cost-effectiveness ratio well below WHO thresholds. The use of LHWs made the approach affordable and sustainable, enabling wider reach in resource-limited settings.

Policy Influence and Scale-Up

National Scale-Up: The AIDS Support Organisation (TASO) scaled up GSP to all its branches in Uganda. The Ugandan military and government programmes expressed interest in adopting GSP nationwide;
International Interest: NGOs in other African countries, such as Nigeria, learned about the project through high-profile talks and are considering implementation;
Government Programmes: GSP was registered with Uganda’s Operation Wealth Creation programme, aimed at ending poverty countrywide.

Research Partnerships and Future Expansion

The project fostered collaborations with the Ugandan Ministry of Health, Global Health Corps, and international research institutions;
Ongoing efforts are underway to expand GSP in Uganda and other African countries, with applications for further funding and partnerships with organisations in Kenya and South Africa;
The intervention is being adapted for younger populations, with funding secured to extend GSP to young people aged 10–18 years.

Community Transformation

The project empowered participants to overcome stigma, become productive members of their communities, and improve their quality of life;
The model demonstrated that it is possible to overcome barriers of poverty, remoteness, mental health stigma, and cultural ignorance to provide comprehensive HIV care in rural areas;

“Individuals treated can return to work and become productive members of the community. Those living with HIV can have improved HIV treatment outcomes hence they are unlikely to continue transmitting the HIV virus.” Ethel Nakimuli-Mpungu

Etheldreda Nakimuli-Mpungu

Etheldreda Nakimuli-Mpungu is a psychiatrist based at Makerere University in Kampala, Uganda. She has a particular interest in depression, anxiety, stress-related disorders, psychosis, bipolar disorder and alcohol-and drug-related mental health problems.