Addressing depression, stress, and hopelessness through an economic and relationship-strengthening intervention: Findings from a pilot randomized controlled trial among people with HIV in Malawi

Background: Depression disproportionately affects individuals in low- and middle-income countries (LMICs). Economic hardship and family strain exacerbate challenges, particularly for women. This study evaluated effects of Mlambe, an intervention targeting economic empowerment and relationship strengthening, on mental health in couples with HIV and unhealthy alcohol use in Malawi. This paper reports the secondary mental health outcomes. Methods: Participants were 78 married couples (156 individuals) with HIV and unhealthy alcohol use (AUDIT-C; 84.4 % sero-concordant positive) from Zomba, Malawi—a district with rural and urban areas. A pilot RCT compared Mlambe (39 couples) to enhanced usual care (39 couples). Mlambe included ten monthly group and individual sessions delivered by trained staff on economic empowerment and relationship skills, with incentivized joint savings accounts matched by the study. Depression (Center for Epidemiologic Studies Depression Scale), stress (Perceived Stress Scale), and hopelessness (Beck Hopelessness Inventory) were assessed at baseline, 10, and 15 months. Linear mixed models tested for between-arm differences. Results: Results demonstrated significant reductions in depression (Cohen's d = 0.41–0.46), stress (Cohens' d = 0.52–0.54), and hopelessness (Cohen's d = 0.26–0.29) in the Mlambe arm compared to control at 10- and 15-month follow-ups (p < .05). Mlambe had a larger effect on women's reports of stress and hopelessness as compared to men (p < .05), with 96 % study retention. Conclusion: Findings underscore the potential of economic and relationship-focused interventions for improving mental health among people with HIV and unhealthy alcohol use in resource-limited settings. Economic empowerment approaches, particularly for women, may be effective in reducing hopelessness and stress.