Impact statement
This study elucidates the benefits of depression treatments for pregnant and postpartum women living with HIV. Antidepressant and problem-solving therapy treatments were administered by trained, nonspecialized medical professionals and lay persons, respectively, demonstrating that quality care and positive mental health outcomes can be realized even in the absence of mental health specialists and at a lesser cost. This model of care eases replication in low-income countries with similar settings. Additionally, our results present timely evidence, especially for the government of Uganda, which recently recommended screening all HIV patients for depression. By bridging the gap of scarce mental health specialists, our results contribute to available evidence advocating for the use of lay health workers in delivering mental health interventions in low-resource settings.
Introduction
Depression is a leading contributor to disease burden among women across the world, and it is common during pregnancy (Concepcion et al., Reference Concepcion, Velloza, Kemp, Bhat, Bennett, Rao, Polyak, Ake, Esber and Dear2023). Perinatal depression, defined as depression experienced in the period ranging from pregnancy through one year postpartum, has global prevalence rates ranging from 15% to 65%, with higher rates in low and middle-income countries (LMICs) (Dlamini et al., Reference Dlamini, Mahanya, Dlamini and Shongwe2019; Dadi et al., Reference Dadi, Miller, Bisetegn and Mwanri2020). Among African women living with HIV (WLHIV), the prevalence of perinatal depression has ranged from 23 to 48% (Ngocho et al., Reference Ngocho, Watt, Minja, Knettel, Mmbaga, Williams and Sorsdahl2019; Nyamukoho et al., Reference Nyamukoho, Mangezi, Marimbe, Verhey and Chibanda2019; Tuthill et al., Reference Tuthill, Maltby, Odhiambo, Akama, Pellowski, Cohen, Weiser and Conroy2021; Abebe et al., Reference Abebe, Gebremariam, Molla, Teferra, Wissow and Ruff2022; Belay et al., Reference Belay, Talie, Tamene, Getnet, Tefera and Geremew2024; Ferede et al., Reference Ferede, Zeleke, Assefa, Nigate and Tassew2025). Perinatal depression among WLHIV has been linked to factors such as intimate partner violence, food insecurity and poor adherence to antiretroviral therapy (Ferede et al., Reference Ferede, Zeleke, Assefa, Nigate and Tassew2025).
Depression not only affects the psychological well-being and quality of life of WLHIV, but it is also associated with reduced adherence to HIV treatment (Concepcion et al., Reference Concepcion, Velloza, Kemp, Bhat, Bennett, Rao, Polyak, Ake, Esber and Dear2023) and has implications for HIV disease management and prevention of mother-to-child transmission (PMTCT) among pregnant WLHIV (Harrington et al., Reference Harrington, Hosseinipour, Maliwichi, Phulusa, Jumbe, Wallie, Gaynes, Maselko, Miller and Pence2018; Waldron et al., Reference Waldron, Burnett-Zeigler, Wee, Ng, Koenig, Pederson, Tomaszewski and Miller2021). Depressed pregnant women with poor adherence to antiretroviral therapy may vertically transmit HIV to the fetus or breastfeeding child, with up to 11% vertical transmission in Tanzania (Ngocho et al., Reference Ngocho, Watt, Minja, Knettel, Mmbaga, Williams and Sorsdahl2019). They can progress faster to advanced stages of HIV by two-fold, are two times more likely to die from AIDS-related deaths, and are less likely to follow doctors’ advice on safe caregiving practices, including vaccines and check-ups for their children (Stringer et al., Reference Stringer, Meltzer-Brody, Kasaro, Stuebe, Wiegand, Paul and Stringer2014) and they have low engagement in HIV care (LeMasters et al., Reference LeMasters, Dussault, Barrington, Bengtson, Gaynes, Go, Hosseinipour, Kulisewa, Kutengule and Meltzer-Brody2020). The mother’s depression can negatively impact the health of the newborn, with risks for HIV acquisition and impaired physical, cognitive and emotional development (Gelaw et al., Reference Gelaw, Zeleke, Asres and Reta2020; Manongi et al., Reference Manongi, Rogathi, Sigalla, Mushi, Rasch, Gammeltoft and Meyrowitsch2020). Despite the widespread burden of depression, depression is rarely diagnosed and treated in Uganda, in part due to the scarcity of mental health professionals (Kigozi et al., Reference Kigozi, Ssebunnya, Kizza, Cooper, Ndyanabangi, Health and PPafua2010).
Collaborative depression care models have been used successfully to deliver depression care in low-resource settings, overcoming human resource constraints through the utilization of trained lay persons and non-specialist healthcare providers (Abas et al., Reference Abas, Nyamayaro, Bere, Saruchera, Mothobi, Simms, Mangezi, Macpherson, Croome and Magidson2018; Psaros et al., Reference Psaros, Stanton, Raggio, Mosery, Goodman, Briggs, Williams, Bangsberg, Smit and Safren2023). One such model is the Maternal Depression Treatment in HIV (M-DEPTH) depression care model, which uses a stepped care approach and evidence-based therapies provided by trained and supervised lay persons [individual Problem-Solving Therapy (PST)] and nurses [antidepressant therapy (ADT)], to treat perinatal depression among WLHIV in Uganda. Use of these cadres to deliver evidence-based mental health interventions helps to address mental health disparities(Barnett et al., Reference Barnett, Gonzalez, Miranda, Chavira and Lau2018) and mistrust because they are members of the community they serve, thus can offer culturally appropriate services in local languages (Kakuma et al., Reference Kakuma, Minas, Van Ginneken, Dal Poz, Desiraju, Morris, Saxena and Scheffler2011; Katigbak et al., Reference Katigbak, Van Devanter, Islam and Trinh-Shevrin2015) and reduce stigma (Morris et al., Reference Morris, Chapula, Chi, Mwango, Chi, Mwanza, Manda, Bolton, Pankratz and Stringer2009; Balaji et al., Reference Balaji, Chatterjee, Koschorke, Rangaswamy, Chavan, Dabholkar, Dakshin, Kumar, John and Thornicroft2012). The use of lay health workers is also cost-effective, especially in low-resource countries (Buttorff et al., Reference Buttorff, Hock, Weiss, Naik, Araya, Kirkwood, Chisholm and Patel2012; Kazdin and Rabbitt, Reference Kazdin and Rabbitt2013).
We recently completed a cluster randomized controlled trial of the M-DEPTH model among 391 WLHIV and found that women randomized to the intervention arm were 80% less likely to be clinically depressed (Wagner et al., Reference Wagner, Gwokyalya, Faherty, Akena, Nakigudde, Ngo, McBain, Ghosh-Dastidar, Beyeza-Kashesya and Nakku2023) at two months postpartum compared to the usual care control group. Other analyses found intervention effects on improved maternal functioning (i.e., self and child care) postpartum; however, these benefits for maternal mental health and functioning did not translate to effects on maternal HIV viral suppression and ART adherence (Wagner et al., Reference Wagner, Gwokyalya, Faherty, Akena, Nakigudde, Ngo, McBain, Ghosh-Dastidar, Beyeza-Kashesya and Nakku2023). To complement and augment the findings from the trial’s quantitative data, we conducted qualitative interviews with a subset of women from the intervention arm to elicit their perspectives on (1) the effects of depression on their HIV disease and pregnancy management, and (2) the effects of depression care on their ability to manage their HIV disease and their role as a new mother. These qualitative data may replicate the results observed in the trial data but also reveal different aspects of what women experienced that are not reflected in the quantitative data.
Methodology
The M-DEPTH depression care model
The M-DEPTH intervention is a stepped care approach to providing behavioral and pharmacological treatments for depression. WLHIV who were attending routine antenatal care visits were screened for potential depression using the 2-item Patient Health Questionnaire (PHQ-2) (Monahan et al., Reference Monahan, Shacham, Reece, Kroenke, Ong’Or, Omollo, Yebei and Ojwang2009) administered by trained lay peer mothers. Those who screened positive (PHQ-2>0) were further evaluated by nurses using the 9-item PHQ (Monahan et al., Reference Monahan, Shacham, Reece, Kroenke, Ong’Or, Omollo, Yebei and Ojwang2009).
Women with minimal, subthreshold depressive symptoms (PHQ-9<10) were provided with depression psychoeducation and monthly monitoring of depression, and active treatment was added if depression increased (PHQ-9>9). Women with PHQ-9>9 were offered treatment: individual PST counseling (up to seven bi-weekly sessions administered by trained peer mothers) was recommended if PHQ-9<20.
PST is a cognitive-behavioral intervention that trains recipients on adaptive problem-solving attitudes and the deliberate and systematic application of four problem-solving skills: problem definition, generation of possible solutions, selection of solutions to use and implementation and evaluation of solutions (Malouff et al., Reference Malouff, Thorsteinsson and Schutte2007; Bell and D’Zurilla, Reference Bell and D’Zurilla2009). Peer mothers were trained to implement manualized individual therapy that consisted of three biweekly core sessions to orient the client to PST principles and methods, followed by up to four ancillary monthly sessions as needed (maximum of seven total sessions) for those continuing to experience depressive symptoms; therefore, therapy was typically completed in four to five months(Wagner et al., Reference Wagner, Gwokyalya, Faherty, Akena, Nakigudde, Ngo, McBain, Ghosh-Dastidar, Beyeza-Kashesya and Nakku2023).
Antidepressant therapy (by trained nurses) was recommended if PHQ-9>19; however, the choice of treatment was ultimately up to the woman. In the case of treatment nonresponse, both treatments were used if recommended by the supervising psychiatrist. These treatments have been used previously to treat depression in SSA, and their use enabled us to include both pharmacologic and psychologic-based modalities of care together with the mobilization of non-specialist and lay health worker interventionists (Chibanda et al., Reference Chibanda, Shetty, Tshimanga, Woelk, Stranix-Chibanda and Rusakaniko2014; Wagner et al., Reference Wagner, Ghosh-Dastidar, Ngo, Robinson, Musisi, Glick and Dickens2016). The treatment model, including training and supervision of interventionists by mental health specialists, is described in further detail elsewhere (Wagner et al., Reference Wagner, Gwokyalya, Faherty, Akena, Nakigudde, Ngo, McBain, Ghosh-Dastidar, Beyeza-Kashesya and Nakku2023).
Study design
This was a cross-sectional study that utilized qualitative methodology. Data for this analysis are from exit qualitative interviews conducted with a small subset of participants enrolled in a cluster-randomized controlled trial of M-DEPTH (Wagner et al., Reference Wagner, McBain, Akena, Ngo, Nakigudde, Nakku, Chemusto, Beyeza-Kashesya, Gwokyalya and Faherty2019). Eight antenatal care (ANC) health facilities participated in the trial, with four randomly assigned to provide the M-DEPTH intervention, while the remaining four provided care as usual. The four sites implementing the depression care model consisted of high-volume public facilities located in central Uganda, three of which were health Centre IVs and one was a general hospital; two were rural and two were in peri-urban settings. Usual care, which included monthly Family Support Groups (FSGs) that provide education and support for PMTCT and pregnancy management, was available to women in both study arms. Enrolled participants completed assessments at baseline and postpartum months 2, 6, 12 and 18. At the 18-month exit interview, a subset of women in the intervention arm were purposively selected and asked to consent to participate in a brief qualitative interview, the data from which is the focus of the analysis reported here.
Eligibility criteria
Women were eligible for the larger trial if they were living with HIV, no more than 32 weeks into their pregnancy, on antiretroviral therapy for at least four weeks and screened positive for potential depression (PHQ-9>4). Given the focus of the interview on the experience of women receiving depression care, only women in the intervention group were selected. They should have received depression treatment (ADT/PST or both), completed the quantitative assessments and been willing to participate. However, we sought a balance between those receiving PST and ADT, and between responders and non-responders. We excluded those who had relocated and were unavailable, together with those who expressed unwillingness to participate. A total of 191 women were randomized to the intervention arm, of whom 129 warranted receipt of depression treatment (83 on ADT, 43 on ADT and 3 received both treatments).
Data collection
Data were collected using an in-depth interview guide that used semi-structured questions to address the topics of interest. Women were asked about the following: (1) their experiences with depressive symptoms, and the effect of these symptoms on their ability to manage their pregnancy, parenting and their HIV disease including taking ART daily and attending clinic regularly; (2) factors that influenced their decision to choose either antidepressant medication (ADT) or problem-solving talk therapy (PST) treatment, including the pros and cons of either treatment, and their expectations for treatment and whether those were met; and (3) their experience with treatment and its influence on their ability to manage their pregnancy, parenting and HIV disease. Interviews were conducted in a quiet and private room with minimal disruptions. The interviews lasted approximately an hour and were conducted primarily in Luganda at the office of the interviewer.
The in-depth guide was translated into Luganda and back-translated to English to ensure consistency. Pilot testing was done among women with similar characteristics outside the study sites. This was preceded by a five-day training of graduate female interviewers. Interviewers were trained in the objectives, tools and data collection procedures.
Consenting was initiated at baseline and repeated before the exit interviews. The consent form was translated into Luganda for women who didn’t understand English and was read to them in a quiet and private room with minimal disruptions. They were informed about the purpose, risks, benefits and the voluntary nature of their participation. Trained female Master’s level graduate interviewers with rich experience in both quantitative and qualitative research collected the data. All the interview proceedings were audio-recorded to ensure that the women’s views and experiences were accurately captured. Since the interviewers had already established rapport with the participants from the previous assessments, it was easier for the participants to open up. A modest fee of 20,000 Ugandan shillings was given as compensation and a transport refund. Women who had relocated to distant places received a transport fee commensurate with the distance.
Data analysis
The interviews were recorded, and transcripts were reviewed for accuracy. This was followed by translating into English and transcribing. Data were coded using Atlas.ti v23. To analyze the qualitative data, we employed a combination of content analysis and a modified grounded theory approach to assess participants’ knowledge and how they constructed meaning from their experiences (Hsieh and Shannon, Reference Hsieh and Shannon2005). The lead on the qualitative analysis used an open coding method, identifying key themes and subthemes within the dataset. This formed the preliminary codebook, which was discussed with the qualitative team to ensure that the identified themes resonated with them. A second social scientist used this codebook to code the remaining transcripts. They made additions to the codebook and recommended changes in consultation with the lead social scientist. We used an iterative process (rather than intercoder reliability testing) to refine the coding. Discrepancies were resolved via discussion and consensus. Salient text units were identified, and the data were organized into a thematic narrative.
Results
Participant sociodemographic characteristics
Results were obtained from 25 women who received either ADT (n=7) or PST (n=15), plus three who received both. Overall, 23 of the women responded to depression treatment, while 2 (one ADT and one PST) did not respond. The age range was between 19 and 37 years; one-third (n=8; 32%) were currently in a relationship, and nearly all (n=23; 92%) had at least one other child besides the child they gave birth to during the study.
Effects of depressive symptoms on HIV disease, pregnancy and parenting management
Several women talked about depressive symptoms, such as low mood, suicidal ideation, not wanting to eat, as contributing to relationship problems, loss of financial and social support and lack of desire to care for oneself and one’s pregnancy.
Indeed, these symptoms affected me and the unborn child because the moodiness sent my husband away from home, so I had no one to support me financially, and the house chores as well. I even thought of aborting the pregnancy because of the numerous challenges I had. (single, on ADT and PST at Buwambo HC IV)
Regarding the effects of depression on HIV care management, one participant reported disclosing her status because she was tired of taking her ARVs in secrecy.
I used to take my medicine, but I used to take it in secrecy because I did not want my husband to know my HIV status, but I got to a point when I was very tired of that situation and wondering how long I was going to hide myself. So, what I did was I got the medicine, because I was tired of the secrecy and always hiding to take my pills, so what I did was I got the medicine from the bag where I was always hiding it, and I kept it in a smaller bag that he had access to. (cohabiting, on PST at Luwero HC IV)
Some women reported being more self-driven in managing their HIV condition without waiting for reminders. They exhibited a higher level of commitment towards the reduction of symptoms.
When I knew that I was depressed, I took care of myself, I had to take care of myself as an individual, I had to take of myself and HIV infected person, I have to take my medication before any other person could tell me or advise me do something I had to encourage myself to do it first. The fact that I was in depression at the same time HIV positive it made me care about myself so much, and I fought to overcome the depression. (single, on PST at Buwambo HC IV)
Decision on the type of depression treatment
Women who chose PST over ADT described this decision as largely determined by fears of depression severity and disease progression, along with the pill burden and accompanying effects of ADT.
I feared the tablets most, but I was badly off, and I would feel that the situation was worsening, and I wanted to speak out my whole heart to get relieved. That one after telling me I didn’t have problems with it [PST] because I would say that what if one day I take poison (cohabiting, on PST at Mpigi HC IV).
For women who selected ADT, their decision was also guided by the severity of the depressive symptoms at initiation, the perceived effectiveness of ADT, and the small pill size, which made it easy to swallow.
What persuaded me to continue taking this medicine was the thoughts, the condition that I was going through. Whenever I would swallow this medicine, it [the bad thoughts] would go [away]. (cohabiting, on ADT at Mpigi HC IV)
General experiences reported with depression treatment
Relief of symptoms
Women noted that the treatment was effective in alleviating depressive symptoms, regardless of the type of treatment they used. Some described the alleviation of depression as transforming their life with benefits observed in several aspects of their life, including improved overall well-being (e.g., less stressed and happier, improved appetite, not feeling suicidal) and better relationships with others.
I am still surprised. I am still very surprised to date because I sit back, and I say to myself that I used to be deeply depressed. I had no appetite. I was not eating. I was not sleeping. I was just there, but when I went through the therapy for depression, I overcame all that. Then I got surprised and asked myself, what did these people give me because my heart had been healed. My heart felt light, and all the burden was taken away. (single, on PST at Wakiso HC IV)
I witnessed changes in my life the moment I started my medication towards depression. Some symptoms started declining, for example, my stress levels reduced, I stopped thinking about committing suicide, started associating with others, and I regained my appetite. I became happy because I was associating with others (single, on ADT at Nakaseke Hospital).
One woman had become pregnant as a result of being raped. This trauma provided a dramatic context for demonstrating the emotional and psychological benefits of depression treatment during pregnancy. She believed that if it weren’t for the depression treatment, her baby would have acquired HIV from her because the rapist was HIV positive. The emotional torture she experienced, if untreated, would indirectly result in an HIV infected baby since she would not take her medicines very well.
I believe the baby would turn out to be HIV positive because the pregnancy occurred as a result of rape, and the person that raped me was HIV positive, and this resulted into hateful mindset in me. (married, on PST at Buwambo HC IV)
Improved mental health literacy
The participants reported that the process of treatment helped them to learn a lot about depression, mental health and its connection to physical and emotional well-being.
The truth is I had no hope, which showed me that I would bring the child up, but like I said earlier, since I started participating in this study, I gained courage and power, just as you advised that you do this with the child, you play with her like this, laugh with her. That is when I got the courage to take care of her, and I managed to see her grow. (single, on PST at Wakiso HC IV)
Two-thirds (68%; n=17) of the participants spoke of depression as being a treatable illness; one-third (36%; n=9) came to realize that they are not alone in their struggle with depression, as they were made aware of how common depression can be in the context of pregnancy.
When I was told about this study, I got concerned and wondered about what kind of thing I was getting myself into. I was asking myself how I was going to be helped. I was so scared about my [HIV] status, and I was asking myself, these people who are asking me questions, how are they going to help me? But I found out later that they had taken me somewhere where I could not have been able to go on my own (cohabiting, on PST at Wakiso HC IV).
It is also noteworthy that most women (76%; n=19) found the nurses and peer mothers who provided their depression treatment to be kind, caring and respectful.
Yes, the truth was that they used to care about me, for sure, if you see a teacher caring about you, and you’re concentrating, mastering, and even putting into practice what they teach you…. (single, on ADT and PST at Buwambo HC IV)
Proper taking of ART medicines
Slightly more than half (52%; n=13) of the women reported an improvement in taking their ART when asked to describe whether depression treatment had an impact on their HIV disease management. This was attributed to the information about the dangers of not taking their ART well and concerns of having an HIV infected baby that would place more burden on their already burdened lives. This information was shared during family support groups and was also linked to the encouragement they received from the nurses and peer mothers. This consequently helped them to honor their appointments consistently. With depression treatment, some women were able to disclose their HIV status to the people they lived with, which also made them more comfortable taking their ART medication.
It changed many things so much. Because like taking my drugs, before I would delay. I would delay taking those drugs, no eating, sometimes you don’t have time, the worries would be so burdensome and you would be thinking about death. (cohabiting, on PST at Mpigi HC IV)
Improved parenting and pregnancy management
With receding symptoms resulting from depression treatment, women were revitalized and ably took care of themselves, their pregnancies and their newborn infants. This was done through enhanced associations with their friends and family members and improved adherence to their treatment.
After getting counseling from the counselors together with my new mind I came to learn that being alone is a very bad thing which affects the health of someone. So I decided to go out of the house and start looking for someone to talk to. It is the same thing when I went home after I had delivered, I managed to get my father’s wives and my in-laws and we have chats; we would talk and laugh, and in the end I realized that my heart had been freed. I realized that I did not have that much depression as I used to have before, and my mind was at peace. (cohabiting, on PST at Wakiso HC IV)
Experiences specific to women on antidepressants (ADT)
All women who received antidepressant therapy reported it to be effective because of its effect on symptom reduction. This was linked to the ease of taking the pill because of its small size and minimal side effects. Those who didn’t adhere to their medications cited side effects of vomiting and loss of appetite, fear of their partners abandoning them and lack of food as some of the reasons for skipping their ADT doses.
I was fearing it, because when I took it the first time, it made me feel bad. However, this one was small and you would just put it in and swallow. So that one treated me ok, but the very first one, whenever I would take it, I would vomit (single, on ADT at Mpigi HC IV)
Experiences specific to women on problem-solving therapy (PST)
Problem sharing and problem-solving skills
Nearly half (44%, 8/18) of women who received PST reported benefits related to sharing their problems with someone else. They spoke of gaining confidence from talking to their health care workers about their mental health struggles, which they couldn’t do before.
I always thought treatment is all about taking tablets, but I was surprised that this way of treatment involved only talking with doctors. But later I got to know that a problem shared is a problem solved. (married, on PST at Buwambo HC IV)
Furthermore, through PST sessions, about two-thirds of women (n= 10) reported learning problem-solving skills, and many learned to plan and move forward with their lives.
I learnt that if you get a problem any time in life you can counsel yourself and it is solved. You can do away with that problem yourself without involving anyone and without worrying about it. (cohabiting, on PST at Mpigi HC IV)
Ancillary benefits of treatment
Further still, through the PST sessions, some women used the acquired skills to start up small-scale businesses using their transport compensation from the study for attending treatment or assessment visits. Developing income-generating activities not only improved their financial circumstances but also made them feel empowered to make changes in their lives.
And from that day I had nothing to get depressed about. When we used to come here, I could get my transport and I save it then I started a chapatti business. I bought a jerry can of cooking oil, I purchased onions and silver fish and it was all getting better. So, this depression was a result of poverty because I did not have anything. So, whenever I would put things together everything was just a mess. But this time round, even when I am called that you are needed, it is not hard for me because I have sold something and I have my transport. (single, on PST at Nakaseke Hospital)
Challenges encountered with depression treatment
While the responses generally highlighted the benefits of depression treatment, some women mentioned challenges posed by treatment. The main challenge for those receiving ADT was the drug burden and difficulty swallowing pills. Long waiting time for peer mothers to become available (as they were attending to other women) and numerous trips to the facility (PST visits were weekly over a few months, while ADT visits were monthly over typically a year) were mentioned by those who received PST.
I am used to swallowing just one pill [for ART], now you are adding on a second one. It was going to become a burden to me. So, I thought really hard, and said that, oh God, should I really take this medicine since the health workers have told me that it reduces depression? (single, on ADT at Nakaseke Hospital)
Discussion
These qualitative interviews with women who received depression treatment highlight how both ADT and PST, when administered by trained and supervised non-specialists, can help women living with HIV to overcome the challenges that depression poses for both HIV disease and pregnancy management. Depression treatment helped these women to adhere better to HIV treatment, take better care of themselves and their newborns and gain a hopeful perspective on their life and ability to cope with stressors.
Available evidence suggests that depression leads to ART non-adherence (Sheth et al., Reference Sheth, Coleman, Cannon, Milio, Keller, Anderson and Argani2015; Ashaba et al., Reference Ashaba, Cooper-Vince, Vořechovská, Rukundo, Maling, Akena and Tsai2019; Abebe et al., Reference Abebe, Gebremariam, Molla, Teferra, Wissow and Ruff2022); therefore, treating depression could improve adherence to ART (Abas et al., Reference Abas, Nyamayaro, Bere, Saruchera, Mothobi, Simms, Mangezi, Macpherson, Croome and Magidson2018; Camargo et al., Reference Camargo, Cavassan, Tasca, Meneguin, Miot and Souza2019; Ouansafi et al., Reference Ouansafi, Chibanda, Munetsi and Simms2021). This was supported by the responses of women in our qualitative interviews, whose experiences indicated that they perceived treatment to be effective. However, results from our quantitative findings in the clinical trial showed no significant difference in ART adherence between depressed women who received depression treatment and those who were not treated(Wagner et al., Reference Wagner, Gwokyalya, Faherty, Akena, Nakigudde, Ngo, McBain, Ghosh-Dastidar, Beyeza-Kashesya and Nakku2023) Similarly, another study found that group PST for perinatal depression did not benefit ART adherence among WLHIV in South Africa (Psaros et al., Reference Psaros, Stanton, Raggio, Mosery, Goodman, Briggs, Williams, Bangsberg, Smit and Safren2023). Our larger study sample was characterized by high levels of undetectable HIV viral load and consistently high levels of ART adherence, representing a ceiling effect that made it difficult to detect a quantitative impact. In contrast, the qualitative interviews allowed us to directly hear from women’s subjective perception of the impact of treatment on their adherence.
Furthermore, our results highlight a positive effect of depressive treatment on pregnancy, self-care and parenting. With a reduction in depressive symptoms, women were able to regain their functional capacity and social skills. This is consistent with quantitative data from the larger trial (Wagner et al., Reference Wagner, Ghosh-Dastidar, Faherty, Beyeza-Kashesya, Nakku, Kisaakye Nabitaka, Akena, Nakigudde, Ngo and McBain2024) and results from (Heath et al., Reference Heath, Fife-Schaw, Wang, Eddy, Hone and Pollastri2020), which showed that reduced parental stress corresponded with improved parental empathy. PST may have been particularly useful in this regard, as it builds skills to manage stressors and challenges that arise, including identifying feasible, effective strategies to limit stressors (McCrory et al., Reference McCrory, Cobley and Marchant2013). This can foster self-efficacy and confidence to manage challenges, including those related to parenting.
While both PST and ADT were administered by non-specialists in the MDEPTH model of depression care, the PST modality went a step further by being administered by peer mothers who are trained lay persons providing largely volunteer assistance in the clinic. This is noteworthy in a resource-limited setting where the availability of nurses is also limited. Furthermore, the peer-led PST has the further advantage of providing a context for women to share experiences and draw peer support from the peer facilitator. Our qualitative data revealed the appreciation that women had for the counseling sessions, providing a safe, welcoming space for sharing personal experiences related to depression and life challenges as women living with HIV and managing pregnancy. Increased comfort with sharing personal struggles allowed women to experience peer support in return. Lastly, several women spoke of PST enabling them to develop the skills needed to address and cope with problems that arose in their lives. Similar findings are reported by Patel et al. (Reference Patel, Rahman, Jacob and Hughes2004).
Women who received PST felt comfortable discussing their secrets with health workers who didn’t know much about them, as opposed to friends and neighbors. They regarded this as an opportunity for sharing because friends and neighbors are prone to spreading their secrets. Confidentiality of patients’ information should be emphasized among health workers, especially those working with the vulnerable.
There are limitations to our data that should be noted. Our findings are not generalizable to all WLHIV, as only those in HIV care were enrolled in this study. Further, among the participants of the larger trial, only those who completed the 18-month post-partum assessment were invited to participate in the qualitative exit interview; therefore, women who prematurely dropped out of the study (and likely postnatal care) were not represented among our respondents. This may contribute to a lack of representation of negative experiences from depression care, although we did purposively include women in the sample who did not respond to treatment. Additionally, the interviews were conducted at the exit point; thus, women could not easily remember some of the aspects of the intervention and the symptoms they had at baseline, and as such, responses may not accurately reflect their full experience of the depression treatment process. Our results might also suffer from social desirability bias, which we mitigated by ensuring anonymity during consenting and during interviews.
Conclusion
Depressive treatment, whether it be ADT administered by nurses or PST administered by peer mothers, was perceived by WLHIV as benefiting not only their mood and mental health but also their ability to take their ART, self-care, care for their newborns and overall functioning. Taken together with evidence from the larger controlled trial, these findings highlight the need for treatment for perinatal depression to be more accessible to WLHIV. The M-DEPTH depression care model relies on non-specialized health care workers, including volunteer lay persons, suggesting that such a model can bridge the gap of scarce mental health specialists. This model may be more feasible and affordable in low-resource settings such as Uganda, but its sustainability remains to be determined. Greater prioritization of mental health care for this population will not only prevent poor mental health outcomes but also enhance parenting skills to promote early childhood development, overall functioning and adherence to ART. We recommend the integration of depression interventions (ADT and PST) into maternal and child health clinics and PMTCT programs in resource-limited countries. Further research on the role of depression interventions on abortion and suicide ideation or tendencies should be explored.
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2026.10135.
Data availability statement
Study data is available from the corresponding author upon request.
Acknowledgements
We acknowledge the support of the health care workers in all the study sites; the women who consented to participate in this study and responded to our interview guides; and the study Investigators for their support and supervision. We thank the National Institute of Mental Health (NIMH) of the National Institutes of Health for their financial support, without which the study would have been impossible to implement.
Author contribution
RK: Contributed to data acquisition, conceptualized and drafted the original draft, and revised it critically for important intellectual content. GW: Substantial contributions to the conception or design of the work, support supervision, funding acquisition, and reviewed and edited the drafts. VG: Reviewed and edited the work, study administration, and support supervision. RKW: conceptualization of the study, funds acquisition, and reviewed and edited the drafts. All authors have approved the final draft.
Financial support
This work was supported by the National Institute of Mental Health (NIMH) of the National Institutes of Health under award number R01-MH115830 (Wagner).
Competing interests
The authors declare that they have no conflict of interest.
Ethical statement
This study was reviewed and approved by the RAND Human Subjects Protection Committee, the Makerere University School of Public Health Research and Ethics Committee, and the Uganda National Council for Science and Technology. Written informed consent was obtained from the participants. The trial was registered by the NIH Clinical Trial Registry NCT03892915 (clinicaltrials.gov). Other details of the trial can be obtained from prior publications (Wagner et al., Reference Wagner, McBain, Akena, Ngo, Nakigudde, Nakku, Chemusto, Beyeza-Kashesya, Gwokyalya and Faherty2019, Reference Wagner, Gwokyalya, Faherty, Akena, Nakigudde, Ngo, McBain, Ghosh-Dastidar, Beyeza-Kashesya and Nakku2023).
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