Written by John Minto
Managing Director
Gede Foundation
At the beginning of the HIV-AIDS pandemic, medical efforts tended to concentrate, understandably, on finding appropriate biomedical responses to what was a strange and devastating illness. In turn, counselling often focused on addressing the crisis which a positive diagnosis brought. However, with the introduction of effective combination anti-retroviral therapy, the possibility, at least in high income countries initially, that people living positively (PLP) could live a normal lifespan started to become reality. This posed a number of challenges for counselling support which increasingly morphed into an approach based on behavioural science, identifying HIV-AIDS as a biopsychosocial illness in which psychological, biological and biomedical factors all interacted with the cultural, social and behavioural. No longer was it possible to consider HIV-AIDS as a purely biomedical condition to treat only with the ‘right medication’.
Consequently, there was increasing recognition, again in many high income countries, of the importance of ensuring that responses to HIV were genuinely comprehensive. That is, prevention, care and support which combined biomedical, psychological and social factors and that, without this framework, health outcomes for PLP were more than likely to be sub-optimal. Research indicated that untreated mental health conditions (especially common mental disorders (CMD) – anxiety, depression and substance abuse) were linked to poor HIV primary care uptake, reduced adherence to treatment regimes, lower rates of retention in care and poor health outcomes overall, including the relative rapidity of disease progression. This tended to reflect the growing understanding of the complex links between HIV and trauma, depression, denial, avoidance and stigma – a range of issues which could not be addressed by a biomedical approach alone.
Services in high income countries have made significant strides in terms of (for example) screening for symptoms such as self-neglect, the smell of alcohol, anxiety, impaired memory, irritability, depression, as well as the potential for suicide (research suggests that suicide among PLP is 3-5 times higher than those who do not have HIV). Some programmes also started to explore the interactions between alcohol, domestic violence and HIV-AIDS, in addition to showing that PLP were more inclined towards developing CMDs while people living without HIV-AIDS yet with the same mental conditions could be in danger of engaging in sexually risky behaviour, thereby raising the possibility of new HIV infections. The symbiotic relationship between mental health and HIV-AIDS was increasingly clear and the high income countries started to act accordingly.
In many low and middle income settings, however, the challenges facing HIV-AIDS agencies in providing truly comprehensive care and support (which includes mental health) have focused on three key challenges –
1.Biomedical Focus
First, many HIV-AIDS agencies and donors retain what is an understandable (from their viewpoint) biomedical focus on testing, care and support. The management of supply chains and care and support centres is pivotally important for the vast majority of PLP and remains, in many countries, extremely well done and represents a huge advance on the earliest days of HIV-AIDS care and support. However, there can be no doubt that more sophisticated counselling for PLP who also experience co and multi morbid conditions linked to mental health is needed in order to augment this biomedical focus. However, for many agencies, treatment numbers remains a key strategic priority and are easier to implement and manage given the availability of compelling biomarkers.
2.Lack of appropriate mental health expertise
Second, even where agencies acknowledge the impact of CMDs on PLP, there are very real issues attached to the shortage of trained mental health professionals who would be responsible for the training and mentoring of health care workers charged with delivering mental health services, especially at the community level. As surveys have shown (for Nigeria) the lack of Psychiatrists (less than 150 in country), Psychologists and Psychiatric Nurses has a significant impact on initiatives which aim to deliver long term mental health care and support at the community level. Efforts to ‘task share/shift’ within primary health centres, for example, are still faced with long term issues surrounding quality monitoring and evaluation of staff trained, especially in terms of complex cases, and,
3.Lack of models re integration
The integration of the treatment of CMDs into HIV-AIDS care and support sounds much easier than it is in reality when one considers the fact that the health workers chosen to have tasks ‘shifted/shared’ into their responsibilities are often already overwhelmed with work and might not be able to handle the more complex mental health cases. In this regard, the decision by some mental health agencies to focus on CMDs is both realistic (because many PLP suffer from them) and practical (training can relatively easily cover CMDs) – but can be accused of over simplifying an extremely complex ‘subject’. There is also a real dearth of rigorous case studies related to how such integration could happen ‘on the ground’, so donor enthusiasm is often muted.
These are all important issues and a number of recent development would suggest that they are being addressed.
First, an increasing volume of peer reviewed research is indicating that for a significant number of PLP, without the screening (and subsequent treatment and/or referral where appropriate and possible) of a range of mental disorders, their care and support will be distinctly sub optimal. Advocating to Government agencies and donors on the basis of rigorous research is essential if changes are to be made in care and support regimes. Certainly, without the effective treatment of depression in particular, HIV-AIDS care and support runs the risk, for a significant number of PLP, of being misguided if focused only on the biomedical.
Second, more work is emerging in relation to ‘task shifting/sharing’ and the limitations (and opportunities) which the proposed approaches are showing. In particular, the WHO’s mhGAP (http://www.who.int/mental_health/mhgap/en/) programme is helping to provide insights into ways in which capacity can be built long term, while a number of studies have suggested that engagement with well qualified members of the diaspora can be effective within medical projects as has been seen in a range of East African settings.
Third, more work is emerging which is testing various approaches to integrating the treatment of CMDs into HIV-AIDS care and support For example, the Friendship Bench in Zimbabwe (http://www.friendshipbenchzimbabwe.com/?page_id=1083) is exploring ways in which to build the capacity of (supervised) community health workers through training on a relatively low intensity psychological intervention based on cognitive behavioural therapy to increase patients’ ability to develop resilience and coping skills. The approach also links lay health workers with quality expertise for monitoring and evaluation coupled with a smartphone diagnostic app.
In Nigeria, this work has helped the Gede Foundation to design an intervention which will, in 2015, (i) undertake a prevalence study of common mental disorders in 1200 PLP in FCT, and, (ii) develop and implement a model of integrating mental health screening and management/treatment into the care and support delivered by HIV-AIDS Adherence Counsellors with a view (largely through high quality peer reviewed research) of advocating for adoption at the national level.
For many people living with HIV-AIDS, the lack of high quality mental health support is proving to be a significant barrier to engagement with appropriate level care. Recent developments have shown, however, that more attention is being paid to these issues in the hope that all HIV-AIDS care and support agencies acknowledge that there can be no health without mental health.
