Mental Health Integration Into HIV Services in Zimbabwe

Purpose: With the rising number of people receiving HIV testing and treatment services, there is an increased need to address the mental health (MH) needs of people living with HIV (PLHIV); both those diagnosed but not on treatment, as well as those accessing treatment services.  Stronger mental health can improve retention rates among PLHIV not on ART, and has been linked to stronger adherence to treatment.  The researchers were examining if you can sustainably integrate MH services into standard HIV services in resource limited countries?

Methods:  A mixed-methods assessment was conducted in Harare, Zimbabwe to determine the feasibility of integrating mental health screening instruments (SSQ, CAGE-AID), stepped care, and referral to HIV and psychosocial support services in the community. In July 2012, a two-day Training of Trainers (TOT) was implemented to strengthen the capacity of 16 “Integration Leaders” to integrate MH services into 9 rural and urban clinics in Zimbabwe.  The training focused on integration of screening tools and utilization of a stepped-care approach to integrate mental health into routine HIV services. The stepped-care model promotes simple interventions first, reserving more complicated interventions for those clients in need. The 16 Integration Leaders took a 10-item pre-test prior to participating in the training as well as a post-test reassessing knowledge after participation in the workshop. Post-training Integration Leaders led trainings among key staff at their respective sites. In December 2012, a follow-up assessment of 30 health care providers, trained by the Integration Leaders through the cascade TOT training, were administered the same knowledge assessment test to assess transfer of knowledge.  During follow-up, semi-structured qualitative interviews were conducted with 12 health care providers in 9 rural and urban clinics and one traditional medicine practice. The qualitative interview questions focused on the providers’ experiences with the cascade training model, integrating mental health screening post-training, their use of and perception of the screening tools, the mental health referral process, documentation, challenges encountered, and recommendations for other facilities interested in integration.

Results: Outcome data from the initial pilot demonstrated that integrating mental health screening tools can help identify mental health problems in clients and also increase staff awareness of mental health problems. The pilot increased comfort level discussing mental health problems with clients and decreased stigma surrounding mental health among providers. Opportunities identified in the scale-up include: (1) improving linkages at the community level to support mental health referrals and activities, (2) further training for more staff on mental health integration including screening, counseling and the stepped-care approach protocol, (3) further guidance to increase use of CAGE-AID screening tool; and (4)  increasing the capacity of Integration Leaders to provide problem solving and programmatic support to all staff at sites carrying out mental health and HIV integration.

Implications: The data provided promising findings that may improve the level of holistic care provided to PLHIV in Zimbabwe.  Integrating mental health screening, stepped care, and referrals into standard HIV clinical services is feasible in resource limited settings.