By John Minto, Managing Director, Gede Foundation
In a growing number of countries (low, middle and high income), recent advances in the biomedical treatment of HIV-AIDS have been matched by a consideration of the prevalence and impact of co-morbid non-communicable disorders, including depression. Research (including Abas, M et al (2014), Depression in people living with HIV in sub-Saharan Africa: Time to invest) is increasingly making a strong case for the recognition of, (i) the relatively high rates of depression in people living positively, (ii) the nature and extent of disabilities which are often linked to depression, and, (iii) the negative impact which depression can have on adherence to HIV treatment regimens and health seeking behaviour in general (such as good diet and getting enough sleep). Insights are also starting to emerge regarding the most cost-effective ways in which to integrate the screening/treatment/referral of depression into existing – and busy – HIV treatment and care routines. Perhaps most vitally, ignoring the impact of depression (and other common mental health conditions) on people living positively is increasingly being seen as counterproductive in terms of delivering cost effective care and support to them.
Given the prevalence of depression in samples of people living positively, it is perhaps surprising that the key issues have remained in the shadows for so long. Although sample sizes have often been relatively small (itself a reflection of the lack of attention given to this important issue), research has shown that depression tends to be more common in people living positively than in the population at large. Studies suggest prevalence rates from anywhere between 8-40%, although the Gede Foundation’s large (1200 people living positively) 2015 prevalence survey (working with the Institute of Human Virology Nigeria and the Network of People Living With HIV-AIDS in Nigeria (NEPWHAN)) of depression will add significant insight to this issue. Research suggests, however, that the incidence of depression tends to reflect a range of factors including economic hardship brought on by HIV coupled with the social stigma often associated with it. Worryingly, some studies have also shown that the presence of depression can even increase the risk of HIV acquisition in some people, making it a priority issue for agencies focused on addressing (ie reducing) the number of new infections.
The impact of depression can be profound, even in relatively mild forms where is it often associated with sadness and poor concentration, both of which can impact on an individual’s ability to ‘function normally’. This is often exacerbated by the stigma which many societies have towards someone who shows outward signs of depression (and is ‘doubled’ if the same person is also living with HIV-AIDS). A vicious cycle can therefore be reinforced for people living positively with comorbid depression. As Abas (op cit) notes, ‘the types of disability seen in depression include negative impact on economic productivity, impaired social roles, reduced ability to perform work roles, loss of relationships, poor child health, physical decline, increased accidents and deficits in problem-solving’. Given the significant human and financial costs involved, it is perhaps surprising that more has not been done to address the prevalence and incidence of depression vis-à-vis HIV-AIDS on a global level – particularly as the incidence of depression is also strongly linked to treatment failure. For agencies seeking to ensure ‘100% compliance’ to HIV care and support, addressing the issues surrounding depression is pivotal.
One of the core conclusions of the growing body of evidence is that for a significant number of people living positively who have comorbid depression, a purely biomedical approach to treatment is at best only partially effective and, at worst, subject to interruption and disengagement. Linked to this is an emerging consensus that one of the most effective ways in which to address depression within people living positively is through the use of relatively simple, structured approaches to treatment based on problem solving therapy, integrated into busy, routine clinical (and other) settings.
As such, there are growing calls for the major HIV-AIDS agencies to –
First, develop site-specific ways in which to detect depression which can be used in busy HIV care and support settings. This implies a need to incorporate the screening/treatment/referral of depression into routine adherence counselling while, at the same time, ensuring that peer support networks are developed for those people living positively with comorbid depression. This reflects the practical understanding of the numbers of people living positively seen at treatment sites and that care and support needs to happen both in clinical and community/home settings and should also, ideally, take into account issues surrounding livelihood strategies (often a key reason for the onset and continuation of many forms of depression),
Second, develop appropriate tools for health staff (and, indeed for all of those caring for people living positively) showing how to engage with clients with low mood and how to provide confidential and sensitive support which takes account of all social factors (often linked to stigma) coupled with developing ways to provide clients with ‘simple, structured problem-solving therapy’ (Abas et al), and,
Third, as a starting point, give priority to the screening/diagnosis/treatment/referral (where possible) for depression for those people living positively with clearly and demonstrably deteriorating viral and immunological indicators, as well as for those showing poor adherence to treatment regimes. This, in turn, suggests giving priority to the establishment of prevalence and impact studies coupled with ways in which to develop short screening scales for depression and ways in which conditions can be treated/referred where appropriate. Longer term, there is clearly a need for medical training related to HIV to incorporate depression and (in time) other mental health conditions such as substance abuse and suicidality.
In 2015, working with key partners and agencies such as IHVN, NACA and NEPWHAN, Gede will complete a major prevalence survey of depression and suicidality among people living positively, while working on ways to develop mental health peer support networks coupled with the integration of screening/treatment of depression into the daily work routines of health providers in both facility and community settings. If HIV-AIDS care and support is ever to be truly optimal for all those who are living positively, then expanding services to include ‘mental health’ is absolutely essential.