Integrating safety planning, problem-solving therapy and peer support for suicide prevention among adolescents living with HIV in Malawi: An application of the ADAPT-ITT adaptation framework.

There are few evidence-based suicide prevention interventions tailored for adolescents living with HIV (ALWH) in sub-Saharan Africa. The safety planning intervention targets acute suicidal behavior through co-creation of actionable coping strategies for use at the onset of suicide-related distress. We utilized the Assessment-Decision-Adaptation-Production-Topical Experts-Integration-Training-Testing framework to adapt and integrate safety planning into an existing Friendship Bench + peer support model for depressed ALWH in Malawi. We conducted interviews with ALWH who reported suicidal ideation or behaviors, their caregivers, healthcare facility leadership and police officers, and focus group discussions with healthcare facility staff, community and religious leaders and teachers in Lilongwe. The study team produced adapted manuals, sought and integrated expert topical feedback, trained interventionists using a training-of-trainers model and theater tested the protocol. Formative data yielded insights into acceptability, feasibility, delivery, content and implementation of safety planning. The final safety planning + Friendship Bench + peer support program consists of one safety planning session, five problem-solving sessions with suicide risk assessment and six peer support sessions. We revised the written Safety Plan to account for limited emergency services, modified the protocol for engaging guardians, integrated suicide assessment into the problem-solving sessions and incorporated suicide prevention activities into the peer support sessions.