To prioritize mental health in the context of HIV we must first place into perspective the HIV pandemic’s treatment trajectory. It is 2023 and I live and work in Cape Town. Clients with HIV face first world challenges now such as adjustment disorders, existential crises related to a new diagnosis, the breakup of a relationship; work stress, and the ongoing struggle finding time to exercise. Some 20 years ago, mental health awareness was bottom rung on Maslow’s pyramid of needs.
Being a doctor having interned and then completed my community service in 2002 I have witnessed the experience of patients on either end of a yawning healthcare chasm. Back in 2002 I recall so many nights at the secondary level referral hospital where I worked in KwaZulu Natal where mental health was a luxury amidst the grapple of bare survival in Umlazi, an informal area close to the airport in the South of Durban.
One of the more beautiful and lush provinces, KZN was also home to the highest rates of HIV infection. Aids denialism was rife and the best that was offered was advice from the government on potatoes and garlic and from the hospital always a white plastic packet of steroids for the severe viral pneumonias which beset those with immune deficiency. Many images stuck with me as it was both harrowing and sad but most of all treating patients with only half the medications that was needed inured one with helplessness. The latter emotion being one that thankfully no longer circulates today in the field of HIV treatment.
In this great edifice of mortar with interlocking corridors, wards and labs in the middle of a large township, we had a small pediatric resuscitation area for more acutely ill babies and children where new patients were treated and stabilized for a few hours while awaiting a bed in the ward. If recovery was quick, some would be able to be discharged home the next morning after a plate of porridge. One could always spot a good immune system a mile away as those that were not infected with HIV clearly responded to medication within hours and then disappeared out the unit amidst a ruffle of discharge papers, penicillin bottles and panada. The cleaners and their grey buckets and mops signaled the turn to morning. Nursing shifts changed, tea was drunk, and a new stream of patients would enter the unit.
Our nursing staff were excellent: extremely caring and efficient. Oxygen tubing piped out the walls everywhere in the PRU. The more exhausted moms draped themselves over the counter with their heads next to their infants. When the shorter hand of the clock wound into the smaller hours of the morning head to toe or head-to-head, all found a place more horizontal. Everyone was wrapped in blankets, thick and big enough to keep a horse warm – the type you will always see at a bus station in Africa or on the end of a bed in winter.
Most babies then infected with HIV didn’t survive and everyone in the blankets would run out screaming and sobbing when a child had passed in the PRU, huddling around each other to give what comfort women throughout the ages have given to each other in the universal sisterhood of motherhood .When you saw a heaving chest beneath head box oxygen and 6 litres per minute oxygen piped out the wall, you had to walk away as HIV positive in those days meant no access to ICU.
Given the vast and rapid improvement of outcomes in HIV after the advent of ART and the implementation of PrEP services in combination with reduced stigma there is now more than ever probably a huge potential for a gap in treatment in HIV and mental health.
It’s no surprise that mental health is often neglected in clinical practise. A clinic in Nigeria documented that 20 % of patients with HIV had a missed diagnosis of depression, which is in keeping with findings from North America and Europe.
Anxiety, substance abuse and post-traumatic stress disorder are common in people living with HIV and are associated with disability and increased mortality in this population.
Women have slightly higher rates of depression than men so therefore women with HIV may have higher rates of depression than men living with HIV. There is evidence suggesting a bi-directional relationship between depression and the immune system. Depression is known to negatively affect the immune system although the underlying mechanisms remain poorly understood. There is also evidence that suggests a direct biological pathway from mental health impairment to poorer HIV health outcomes, especially in the context of depression.
Treatment of depression especially the moderate to severe variety has been associated with improved ART (Antiretroviral treatment) adherence.
Screening and triage might be conducted by a lay health worker who could refer patients to mid -level and speciality service where needed. Stigmatization of mental illness may also make people reluctant to disclose symptoms. The broader challenge is that most people (70 -85%) with mental disorders, across all country settings, do not receive the needed mental healthcare, in part because they are not even identified as having a mental health disorder.
The high efficacy of PrEP (Pre exposure prophylaxis) has been shown to significantly reduce symptoms of anxiety and depression among young people. It promotes greater engagement and screening for not only mental health challenges but other illnesses like diabetes, high blood pressure and substance use. However, mental health problems can also interfere with efforts to prevent HIV infection, including regular HIV testing and adherence to PrEP.
Modern electronic and other remote solutions can be adopted which would support efficient utilization of higher-level clinicians. Meditation and mindfulness Apps are more commonplace. Internet based mental health interventions, such as internet based cognitive behavioural therapy are growing in popularity globally to improve access in low resource settings. Still much more is needed in terms of screening and access to mental health services.
The Department of Health in collaboration with Reach Digital Health, Avert and Elton John AIDS Foundation have launched the Young Africa Live Smart Bot -a WhatsApp platform designed to help young people during the adolescent stage around topics of love, relationships, STI’s, contraception, HIV and mental health etc. The establishment of this youth targeted initiative was informed by a high rate of teenage pregnancy and HIV infections amongst young people. A Youth Sex Survey conducted in 2012, found that at least 60% of randomly surveyed 17000 South African adolescents responded that they are not open to discuss or ask their parents about sexual issues. The WhatsApp platform provides a space for the young to explore features, request a call from a qualified counsellor, search for services nearby, or ask questions.
On a very fundamental level there can be no health without mental health. Our challenge is to keep the gap in mental health access smaller than the gap that existed to access ART.
By Dr Wendy Dicks
References:
Prioritizing mental health in the HIV/AIDS Response in Africa
Catherine Godfrey, M.D, and John Nkengasong Ph.D.
August 17 2023
N Engl J Med 2023; 389:581-583
AIDS 2019 Jul 15; 33(9):1411-1420
Mental health and HIV/AIDS: the need for an integrated response
Article from News24 14 Aug entitled “Department launches Whatsapp platform to empower youth with sexual Reproductive Health information’’
