When asked what she needed the woman spontaneously requested a double dose of mental health care and support; Duong Sinh TuNa is a rhythmic poem recited during relaxation and stretching exercises hosted at the clinic for people living with HIV (PLHIV). It reads in part: “Breathe, Meditate, Relax, Exercise, Think Positively…Healthy Minds, Clearer Thinking, Helps Recovery.”
Thanks to better access to antiretroviral therapy (ART), people living with HIV are living longer — typical, complex lives, full of tough and joyful moments, with instances of happiness ideally outnumbering hardships. Addressing the mental health of PLHIV is central to a comprehensive approach that meets their holistic needs. With treatment accessible on a global scale, PLHIV are able to live normal and active lives for many years; yet mental health needs of PLHIV are often overlooked in care, treatment and support programs.
An individual’s well-being provides scaffolding that underpins everything he or she does. Well-being facilitates opportunities to form relationships, to love, to work, allowing a person to continue making choices that support good health. World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community”, a definition that should inform all programs and policies targeting individuals living with HIV.
Indeed, as more and more PLHIV live longer many specific and common mental health problems, such as anxiety and depression, can go undetected and untreated. This has profound effects on quality of life, ART adherence, retention in care, immunological status, symptom severity, morbidity, and mortality, all of which combine to influence HIV progression. In December 2009, AIDSTAR-One produced a technical brief to highlight MH issues of PLHIV, demystifying mental health and guiding programmers in resource-limited countries. Building on this technical brief, my colleague Mary Gutmann and I visited programs in Vietnam and in Northern Uganda to document existing models of MH and HIV integration. Both models of integration show successes and challenges that can guide programs and policies.
In Vietnam the FHI program integrated mental health into existing HIV care and treatment services. The case study describes how HIV providers were trained in screening for anxiety and depression, so they could provide care and referrals for additional treatment and support. Vietnam worked from a strengths-based positive perspective, using yoga, nutrition, medication, counseling, behavioral, and pharmacologic treatment to improve well-being.
In Uganda, the conflict in the North stabilized in recent years, however a generalized HIV epidemic remains. Providers grew concerned that they needed to address HIV as part of mental health services. Under a program implemented by the Peter C. Alderman Foundation (PCAF), mental health providers (social workers, psychiatrists, psychiatric nurses, and psychologists) were trained in HIV, giving them the skills to refer and accompany people to access HIV services. In this model, the special MH needs of PLHIV are integrated into existing MH Services.
What did we learn when visiting both these sites a world away? PLHIV benefit from services that recognize how mental health and physical well-being work together to improve quality of life. Depression and anxiety are just as common among people living with HIV as those without. And when service providers are armed with skills in both mental health and HIV, they can offer holistic, much-needed support to PLHIV.
Key things for programmers and policy makers to note include:
1) Start small: Vietnam’s pilot program first used a 20-question MH assessment to refer for MH services, quickly realizing this detailed assessment was too cumbersome for providers/clients. When the program reduced the screening to two flag questions, referrals for MH services became a simple step for providers to include when meeting with clients in the clinic or during a home visit. In 2006, PCAF’s pilot program started in Northern Uganda, a non-conflict area, field testing the model in a less challenging environment. Setting up monitoring and operational systems there provided a road map for the three clinics in the post-conflict North (Gulu, Kitgum, and Arua).
2) Use data to inform practice: Both programs would benefit from a comprehensive situational assessment of mental health of PLHIV. The Vietnam program stood out as evidence-informed practice with quality of life indicators being regularly measured. Results showed strong improvement in quality of life after the FHI intervention. In Uganda, data collected/analyzed since September 2009 was used to help document services and explore and respond to gaps in a more systematic manner.
3) Meet the needs of women and men: In both countries, MH services were utilized more frequently by women, reinforcing the need to develop stronger techniques for better engaging men living with HIV. Also, programs should be able to respond to gender-based violence.
4) Assure quality of mental health services: The program in Vietnam had strong checks in place to ensure quality of services, with frequent refresher training for all cadres of staff. In Uganda, psychiatric consultants visit the PCAF clinics regularly to monitor treatment and provide supervision to counseling staff. However, refresher trainings are not regularly scheduled in Uganda due to lack of funds.
5) Model appropriateness: In Uganda, the cost-effectiveness and high level of integration within the Ministry of Health were strengths that also resulted in service gaps—staff and clients mentionedlack of outreach services and staff-refresher trainings. Embedded in the overall health system, the Vietnam model received a much higher level of financial support to provide the program with stronger quality assurance measures, stronger outreach/community services, and regular supportive supervision/training.
6) Referral systems: Although the Uganda model had strong referral mechanisms in place at the existing government-run MH clinics, there were large gaps in referral mechanisms between HIV/AIDS service organizations and community services. The Vietnam program was well integrated at both the ministry and community level.
7) Going beyond pharmacological treatment: Both programs stressed the key role positive living plays in health, using interventions like family therapy, nutrition, meditation, yoga, peer group support, and cognitive behavioral therapy in addition to medication if needed.
8 ) Country Ownership: The Vietnam Government plans to scale up MH services in HIV clinics. In Uganda, the public-private partnership among PCAF, Makerere University, and the Ministry of Health was essential in selecting sites for services, providing in-kind support, and creating the sustainable staffing model PCAF uses to provide services. Both efforts have large buy-in and are led by each respective Government.
9) Sustainability and Health Systems Strengthening: In Vietnam the team consulted with the relevant Ministries with each step and used an NGO to provide TA, while also increasing the capacity of all HIV staff to assess, refer, and provide MH services. In Uganda, all services started directly under key MH leaders in the Psychiatric Department and Makerere University. These stakeholders provide in-kind support in the form of technical supervision, medicines, and space. Both programs worked within the systems to improve services and strengthen human resources. Provision of supplies/medicines and ongoing training were incorporated into each program with varying degrees of success.
AIDS Support and Technical Assistance Resources, Sector I, Task Order 1 (AIDSTAR-One) provides rapid technical assistance to the U.S. Agency for International Development (USAID) and U.S. Government (USG) country teams to build effective, well-managed, and sustainable HIV and AIDS programs and to promote new leadership in the global campaign against HIV.
Managed by the Implementation Support Division of USAID’s Office of HIV/AIDS and implemented by John Snow, Inc. (managing partner) and its partners, AIDSTAR-One provides targeted assistance in knowledge management, program implementation support, technical leadership, program sustainability, and strategic planning.