A wise man once said, “Without mental health there can truly be no physical health”.
Emerging evidence is demonstrating the accuracy of this statement particularly in the lives of people living with HIV (PLHIV). The occurrence of mental health problems among PLHIV is truly alarming; the prevalence of depression is estimated up to 72%, and anxiety rates are five times higher when compared to those not diagnosed with HIV. Aggravating an already difficult situation, more than 76% of all people with severe mental health issues go without treatment in low- and middle-income countries.
In many countries there are not enough trained personnel to address the needs. For example, in Zimbabwe, more than 50% of health posts are vacant and 90% of the country’s psychiatric nurses work at one hospital in the capital city of Harare. These startling numbers provide evidence that addressing the strictly clinical needs of PLHIV is no longer enough and begs the question, how can we as public health professionals think outside the box to address the mental health needs of PLHIV?
Recognizing the need to build creative models of mental health services for PLHIV, starting in 2011 through the PEPFAR funded AIDSTAR-One program, JSI began a pilot study to integrate mental health into routine HIV services in 5 districts in Zimbabwe. Working together with the mental health, HIV, and traditional medicine departments within the Ministry of Health and Child Welfare, we designed a program that provides a basic package of services including mental health screening, basic counseling interventions and referrals for psychosocial and higher level mental health services.
Findings from a preliminary situational analysis found that the majority of Zimbabwean PLHIV visit a traditional medicine practitioner prior to entering the formal health system. Upon learning this, we realized that a community-wide approach would tremendously increase the likelihood that a person accessing HIV services would be exposed to the mental health intervention.
We then initiated the pilot study by training trainers, using a cascade approach to train clinicians, community health workers, and traditional medicine practitioners to screen for common mental health problems including alcohol and substance use, and to provide basic therapeutic interventions. They also make referrals to higher levels of care for further counseling and/or medication management as needed. Supportive supervision, peer support, and job aids were also provided.
Following the four-month pilot study, we at JSI held focus group discussions among health and community providers and traditional medicine practitioners who agreed that integrating mental health and HIV services was feasible. In fact, focus group participants said that a mental health screen should be a standard of care similar to that of a blood pressure check.
After just four months of services, the providers also reported reduced stigma, and increased comfort with mental health screening and counseling. We were absolutely stunned to learn that of all clients who screened positive for depression and anxiety in the pilot study, an alarming 61% voiced suicidal ideation.
The way forward is clear; it is time to move beyond the traditional concept of HIV clinical care to address the mental health needs of PLHIV. The Ministry of Health and Child Welfare in Zimbabwe agrees. They are now using a Standard Operating Procedure that emerged from the pilot study to plan for nationwide scale-up. We are hopeful that as HIV programs move to integrate mental health screening and services, improved clinical and quality of life outcomes for PLHIV will become an inevitable outcome. Since ending the pilot project in Zimbabwe, we are happy to report, this is already starting to occur.
 World Health Organization (2013). No Physical Health without Mental Health: Lessons Unlearned? http://www.who.int/bulletin/volumes/91/1/12-115063/en/
 Adewuya AO, Afolabi MO, Ola BA, Ogundele OA, Ajibare AO, et al. (2007) Psychiatric disorders among the HIV positive population in Nigeria: a control study. Journal of Psychosomatic Research 63(2): 203-6.
 World Health Organization (2013) Mental Health Action Plan (2013-2020). Geneva, Switzerland. Available: http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021_eng.pdf Accessed September 2013.
 Pitorak H, Duffy M, Sharer M (2012) There is no Health without Mental Health: Mental Health and HIV Service Integration in Zimbabwe, Situational Analysis. Arlington, VA: USAID’s AIDS Support and Technical Assistance Resources, AIDSTAR-One, Task Order 1. Available: http://www.aidstar-one.com/focus_areas/care_and_support/resources/report/mentalhealth_zimbabwe