Mental health conditions occur at higher rates among people living with HIV than among people without HIV, in both North America and Africa. Mental health is often neglected in clinical practice, however, despite associations between these conditions and poor health outcomes. One clinic in Nigeria documented that 20% of patients with HIV had a missed diagnosis of depression,1 for example, which is in keeping with findings from Europe and North America. Most of the literature on psychiatric conditions among people with HIV focuses on depression. In research conducted in sub-Saharan Africa, the prevalence of major depressive disorder ranged from 13% to 24% in mixed groups of people with HIV on and off therapy.2 Anxiety, substance use disorders, and post-traumatic stress disorder are also common among people living with HIV and are associated with disability and increased mortality in this population.3
Various mental health conditions may be risk factors for HIV infection, and when such conditions coexist, risks may be compounded. Mental health conditions can also complicate HIV treatment: depression, for example, is associated with reduced adherence to antiretroviral therapy (ART). There is growing recognition within our program — the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) — and among other donors, HIV program leaders, policymakers, and governmental partners of the importance of mental health. But few specific programmatic efforts have been devoted to improving mental health as part of initiatives aimed at ending HIV as a public health threat in Africa.
Some populations of people living with HIV may be at particularly high risk for coexisting mental health conditions. Women are more likely than men to have depression during their lifetime, and women with HIV may have higher rates of anxiety and depression than men with HIV. During the peripartum period, ART adherence challenges associated with postpartum depression may affect the risk of vertical transmission. The World Health Organization (WHO) estimates that one in seven adolescents 10 to 19 years of age has a mental health problem; the prevalence may be higher among young people living with or at risk for HIV. Men who have sex with men are known to have a higher risk of depression, substance use, suicidal ideation, and suicide attempts than heterosexual men.
The association among mental health conditions, poor engagement in HIV treatment, and poor HIV-related outcomes is well documented. In a large meta-analysis, which included more than a dozen studies conducted in Africa, the likelihood of having good (at least 80%) ART adherence was 42% lower among people with depressive symptoms than among those without depressive symptoms.4 The effects of successful treatment of mental health conditions on HIV-related outcomes are less well defined, however, and few studies on this topic have been conducted in Africa. One meta-analysis of U.S.-based studies involving people living with HIV distinguished between interventions designed to treat depression and those providing psychosocial support aimed at relieving psychological distress and promoting mental health.5 This distinction is important because psychosocial support can be conflated with treatment for mental health disorders. Treatment of depression, especially moderate-to-severe depression, was associated with improved ART adherence. Interventions focused specifically on supporting adherence weren’t as effective as interventions for the treatment of depression.5 Emerging evidence suggests that interventions that are centered around problem-solving skills and delivered by trained lay counselors might be an effective and scalable approach for supporting people with HIV and mental health conditions.
The lack of trained mental health professionals is a global challenge and an especially critical problem in Africa. According to the WHO, there was one psychiatrist for every 500,000 people in the WHO African region in 2022, a ratio that’s one hundredth of that recommended by the agency. Several models have been proposed for addressing mental health needs in resource-constrained settings. Task sharing has emerged as an important care model, and several task-sharing approaches have been found to be associated with improvements in mental health symptoms, including methods involving screening and referral by nurses in primary care settings and brief interventions delivered by lay health workers. Transdiagnostic approaches involve providing a single therapy to people with multiple mental health conditions, usually when such conditions cause overlapping symptoms. Such interventions aren’t specific to people living with HIV, and data on their effects on HIV-related outcomes are lacking. These approaches, however, have been used successfully in a few African countries among people with mental health conditions that affect those with HIV.
The Covid-19 pandemic led to expanded use of telemedicine and other remote interventions. In Africa, these methods have been used to support community health workers involved in direct patient care and oversight. Such approaches also hold promise for psychiatric interventions. Screening and triage activities might be conducted by a lay health worker, who could refer patients to mid-level and specialty services when necessary. There is a robust literature supporting the need for supervision of mental health workers, particularly in community practice. Such supervision could be amenable to remote solutions.
The need to address coexisting mental health conditions — which can both increase the risk of HIV acquisition and affect HIV treatment outcomes — is acute in Africa, where most of the people living with HIV worldwide reside. Several screening tools are available, some of which have been evaluated in low- and middle-income countries for specific conditions. Further work developing screening and diagnostic tools will be needed, and clinicians will require training in the use of these tools. Stigmatization of mental illness and criminalization of behaviors associated with a high risk of HIV transmission may also make people reluctant to disclose relevant mental health symptoms, even when screening and treatment programs are in place.
There are several steps that we believe could help address mental health programming gaps among people living with HIV in Africa. First, screening tools that can identify coexisting mental health conditions and can be used by community health workers could be rolled out on a broad scale. These tools will need to be validated in various settings in Africa and for people living with HIV. Effective and validated short cognitive–behavioral interventions, tailored to the cultural context and delivered by various health care professionals, will need to be disseminated. Outcomes related to both mental health and HIV should be measured to determine which interventions are effective and the benefit associated with each component of an intervention. Modern electronic and other remote solutions could be adopted and adapted for mental health interventions in Africa, which would support efficient utilization of higher-level clinicians. Mid-level clinicians and community health workers will also need training to provide mental health care within a framework that makes effective use of higher-level clinicians and existing structures. Finally, data could be analyzed in a way that permits refinement of screening and intervention tools and facilitates broader understanding of the effects of coexisting conditions on both individual people and the community.
Deploying simple ART regimens, task shifting to mid-level clinicians, and taking advantage of economies of scale have allowed PEPFAR to bring ART to millions of people. Ensuring that both treatment and prevention gains are sustained will require addressing coexisting mental health conditions as part of the HIV/AIDS response. With community and governmental leaders, recipients of care, treatment providers, and our academic and research partners, PEPFAR intends to explore how the program’s model of care can be used to address coexisting mental health conditions among people living with HIV.