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Better depression care could improve outcomes for HIV treatment programmes
Roger Pebody, 2017-02-21 16:40:00
Improved management of depression and other mental health
disorders has the potential to improve the outcomes of HIV treatment
programmes, Pamela Collins of the National Institute of Mental Health told the Conference on Retroviruses and
Opportunistic Infections (CROI 2017) in Seattle last week. Mental
health treatment should be integrated into HIV services in resource-limited
settings, she said.
Diabetes, cardiovascular disease, cancers, lung disease and
other non-communicable diseases have an increasing impact on the health and
quality of life of people living with HIV. Health services in low and middle
income countries have been slow to implement programmes to prevent, screen for
and treat these diseases, but a number of projects have shown that this work can be
integrated with HIV care.
Dr Collins noted that mental health disorders are now
considered alongside non-communicable diseases in the third Sustainable
Development Goal. But she said that whereas other non-communicable diseases
increasingly affect people as they get older, the greatest burden of mental
health problems falls in adolescence and young adulthood. Around three-quarters
of mental health disorders have begun by the age of 24.
A global meta-analysis showed that 18% of people had
experienced a mental health disorder in the previous year and 29% had done so
in their lifetime (23% in low and middle-income countries, 32% in high-income
countries). However few people receive the treatment they need, especially in
Mental health disorders commonly occur in people living with
chronic health conditions (including HIV). The evidence from a range of conditions,
such as diabetes, asthma and arthritis, is that having untreated depression as
well as another health condition is associated with being less able to function
and having poorer health status.
Depression is the most common mental health co-morbidity experienced
by people living with HIV. In sub-Saharan Africa, the average prevalence of
depression in people living with HIV is around 8% (similar to that seen in
general population samples in the region), but can be much higher in some
Depression is more commonly experienced by women, older
people, those who are unemployed, people with low CD4 cell counts and people
with more physical symptoms. People who have experienced childhood trauma or
negative life events, and those with less social support are more likely to be
The relationship between mental health disorders and HIV
works in both directions, Collins said. Mental disorders can be a risk factor
or increase vulnerability to HIV infection. At the same time, people may
experience depression or anxiety as they adjust to a diagnosis or live with a
chronic illness. Moreover, neuropsychiatric effects of the virus can in some
cases lead to cognitive changes or dementia.
HIV medical care and antiretroviral treatment specifically is in itself
associated with improvements in mental health, due to the improvements in
physical health which it brings. Nonetheless a number of cases of depression
persist, requiring intervention above and beyond the provision of ART.
around 15% of adults and 26% of adolescents living with HIV cite
feeling depressed or overwhelmed as a barrier to HIV treatment adherence. A meta-analysis of studies
mostly conducted in the United States suggested that treating depression
can improve adherence to ART. When the interventions specifically targeted
depression (rather than treating it as a secondary objective), results were
better. Furthermore the greatest impact was seen in patients with a low CD4 cell
count or moderate to severe depression symptoms, or when treatments of a longer
duration were used.
recent prospective cohort study from Tanzania found that 58% of women
beginning HIV treatment had symptoms consistent with depression, with around a
third mentioning each of the following – loss of sexual interest, low energy,
worrying too much and blaming themselves. One in six women said they sometimes
felt like ending their life.
Depression was associated with mortality in this study. Two
years after beginning HIV treatment, 6.6% of women with depression symptoms and
3.7% of other women had died. After adjustment for other factors, women with
depression symptoms were twice as likely to have died.
One of the challenges of addressing mental health is the
dearth of mental health workers in many settings. There is one mental health
worker per 100,000 people in low-income countries, compared to 52 workers per
100,000 people in high-income countries.
Task shifting is therefore key. In a recently
published randomised controlled trial, lay health workers in Zimbabwe were
trained and supervised to provide individual problem-solving therapy. Those who
received the intervention (42% of whom had HIV) had fewer depression symptoms
after six months. The evidence base for task shifting in mental health in resource-limited
settings has grown considerably in recent years, Collins said.
To give another example, a small pilot
study in Cameroon used depression care managers, a non-physician role that
can be fulfilled by nurses or social workers after training. Working within
HIV clinical services, they provided support to an HIV clinician, giving advice
on depressive symptoms and the use of antidepressant medication, based on a
After four months, nearly all participants had a considerable
improvement in their depressive illness. The intervention also appeared to
have an impact on HIV outcomes, including CD4 cell count, viral load, symptoms
Uganda, a group support psychotherapy intervention for people with
HIV, using problem-solving and cognitive-behavioural approaches, reduced
depression symptoms. Support groups exist in many settings, Collins said, but
can be enhanced by adding evidence-based interventions for depression.
Integrating care for mental disorders and HIV is feasible,
she said. This means making the screening and treatment of mental disorders a
normative part of HIV care. Consensus needs to be achieved on who delivers
services – nurses, adherence counsellors, community health workers, peers or
other groups. People seeking services, healthcare providers, managers and
policymakers need to be involved in decision making about service integration, she said.