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A call for strengthened collaboration between mental health and HIV and AIDS programmes in Africa
Andy Seale, UNAIDS
February 07, 2008

http://www.healthdev.org/cms/index.asp

 Poor access to mental health care for people infected and affected by HIV combined with poor access to HIV prevention, care and treatment for people with mental health needs were key themes discussed at a World Federation for Mental Health expert forum convened in Cape Town, South Africa, this week (29-31 January 2008). The meeting heard how service gaps can lead to undue suffering, a loss of quality of life, and poor uptake of, and adherence to, HIV prevention, treatment and AIDS care programmes.

The forum of 23 leaders from different specialties within the AIDS and mental health fields, explored mental health needs for all aspects of the AIDS response with particular attention focused on the needs of carers, people living with HIV and vulnerable children - groups identified as often experiencing the most significant mental health challenges as a result of AIDS. Research presented, conducted by the South African Depression and Anxiety Group and Wits University, Johannesburg South Africa, found that 89% of home based care workers in North West Province and Mpumalanga were depressed or showed signs of depression. World Health Organization consultant Melvyn Freeman referenced a study in Zambia that showed 85% of pregnant women diagnosed HIV positive had episodes of major depression and many had suicidal thoughts and data revealing increased depression and suicide among AIDS orphans in East and Southern Africa.

The Cape Town forum was convened in part thanks to the advocacy of national level organizations including the Zimbabwe National Association for Mental Health which has continually pushed to raise awareness of the need for increased mental health support services to be made available to caregivers of people living with HIV and AIDS and of children who are orphaned when their parents die of AIDS. The meeting concluded with participants agreeing to support a World Federation Mental Health Africa Initiative on AIDS that will raise the profile of existing collaborative efforts, best practices and tools and further mobilize and bring together organizations committed to greater collaboration between the mental health and HIV fields.

Secretary General of the World Federation for Mental Health, Preston Garrison, said: "It is clear from our grassroots partners and members that there is demonstrated need for strengthened mental health services addressing stress management, social support and self-esteem among people living with and affected by HIV. Caregivers in particular experience high levels of stress and their role can take a substantial mental health and physical toll as they care for the physical, emotional and economic needs of their family members."

In a key note presentation to the meeting Frank Njenga, President of the African Association of Psychiatrists and Allied Professions, offered an overview of the status of mental health in Africa emphasizing how the trauma of AIDS experienced by individuals, families and communities has significantly increased the need for an urgent scale-up of comprehensive mental health services that work in collaboration with national and local AIDS programmes.

UNAIDS Senior Advocacy Adviser, East and Southern Africa Region, Andy Seale, presented key principles and priorities that guide national AIDS responses. He said: "The relationship between HIV, mental health and the pursuit of well-being is multi-layered and offers many opportunities for strengthening, scale-up and increased collaboration. Many aspects of HIV-related mental health needs have been addressed at the community level for years - however local needs - particularly of people living with HIV and those with an increased care burden - are often inadequately addressed and programmes remain under resourced and could benefit from increased international support and advocacy."

A series of roundtable discussions on day one of the meeting explored gaps in mental health that need to be addressed in order to optimize the well-being of people infected or affected by HIV in Africa. A number of important contributions were made by participants, several points are captured below:

  • Moderating the discussion, Elizabeth Matare, Chief Executive of the South African Depression and Anxiety Group, urged priority to be given to support interventions reaching home based carers and orphans and vulnerable children. She also highlighted the need for interventions targeting prevention and specifically programmes for at risk communities particularly young people engaging in substance use. The need for increased integration of the needs and voices of people with a disability or people experiencing mental health problems was highlighted by Sylvester Katontoka, President of the Mental Health Service Users Network of Zambia. He said: "Any new intervention should seek to support the greater empowerment of people with mental health problems to respond to their own HIV needs."
  • Lindiwe Chaza-Jangira, National Director of Zimbabwe AIDS Network, emphasized the importance of interventions that looked at all aspects of the AIDS response: "In addition to looking at the consequences of HIV on increased incidence of mental health problems we also need to better understand how mental health problems increase the vulnerability of individuals to HIV infection. Increased community-level support to individuals receiving a positive diagnosis is also needed, in particular in addressing issues around confidentiality, disclosure and handling stigma." Lindiwe also highlighted the need for different levels of support for different types of care-givers - including the many care-givers who themselves are HIV positive and to the specific needs of child-headed households.
  • Derek Von Wissell, Director of the National Emergency Response Council on HIV-AIDS for Swaziland, raised the need to increase health service capacity in order to deal effectively with the range of mental health needs posed by AIDS: "A key issue is working together to expand the capacity of health services where we often see staff under a great deal of pressure to deal with hundreds of patients in a short space of time. Time and resource pressure often result in patient-clinician counselling interactions that should take 30 minutes reduced to only five minutes."
  • Julian Sturgeon, National Manager of the Treatment Action Campaign in South Africa, highlighted the work of the organization's treatment literacy programme run by trained Treatment Literacy Practitioners using well designed training materials as part of a learning curriculum designed to ensure optimum adherence to treatment among people living wtih HIV. Julian suggested TAC materials could be easily adapted and used across the Africa region.
  • June Koinange, of Feed the Children in Kenya, expressed the need to train key community leaders who can multiply further community mobilization on AIDS and mental health and who can assess other emerging or urgent needs for example in relation to nutrition and economic need. "Community mobilizers are key to securing the action needed to respond to needs when they arise at community level." Cascade-style training and the development of materials and methodologies to support the mainstreaming of mental health and HIV issues into broader programmes was raised as an important roll out strategy by Vivi Stavrou, Deputy Executive Director of the Regional Psychosocial Support Initiative. Many participants also raised the issue of the need to ensure an appropriate quality of counselling offered to support different aspects of the AIDS response including HIV testing, treatment and care. Kevin Kelly, Director of the Centre for AIDS Development, Research and Evaluation, suggested that the Africa Initiative supported increased and ongoing professionalization of counselling supported by an appropriate qualifications framework.
  • Sheila Ndyanabangi, Principal Medical Officer for Mental Health in Uganda's Ministry of Health, raised the importance of providing clear information for people explaining treatment options and other HIV interventions. She also proposed the devlopment of training materials for key professionals: "We need to design materials for health workers at the front-line of both HIV and mental health that will support their ability to integrate support across HIV and mental health and identify appropriate interventions."
  • Ben Chirwa, Director General of the Zambia National AIDS Council, guarded against launching an initiative on mental health and HIV that could be perceived as brand new more than 20 years into the response to AIDS reminding the meeting that mental health principles and approaches already underline most AIDS responses. Connie Wambui Mureithi, Coordinator of the Eastern Africa Region of the Society of Women and AIDS in Africa, also advocated that in moving forward attention is given to a full assessment of what is already being provided including an assessment of gaps in service provision with a particular interest in ensuring quality standards for service provision.
  • Rita Thom, of the University of Witwatersrand Division of Psychiatry, suggested possible future collaboration on a joint HIV and mental health intiative targeting health care workers in order to reduce the mental health and HIV related stigma often experienced in health care settings.

On the second day of the forum examples of programmatic interaction, integration and opportunity between HIV and mental health were presented from a number of countries including Kenya, Swaziland, Tanzania and Zambia and also from a closely intergrated project based from outside the region in Goa on the west coast of India.

Following the presentations Arvin Bhana of the Human Sciences Reasearch Council, challenged future collaboration to ensure that a key focus would be to share best practices, tools and experiences. Lindiwe Chaza-Jangira, National Director of Zimbabwe AIDS Network, expressed support for a move towards a greater standardization of mental health and well being programmes to strengthen the many community based initiatives already focused on psycho-social support.

In conclusion, the forum, which was supported by the Ford Foundation, agreed to move forward in mobilizing an Africa-wide initiative to address the complex and multiple interactions between mental health and AIDS through a focus on community-level mobilization. The intiative will seek to mobilize further interest at the African Psychiatric Conference to be held in Ghana in April 2008, compile an online directory of joint HIV and mental health resources, develop a series of policy papers and information packs for key workers, and convene a partners' conference in early 2009 exploring the mental health consequences of AIDS for people living with HIV, their families, caregivers and communities.

For further information see the World Federation for Mental Health Website at www.wfmh.org or email info@wfmh.com . A full report on the expert forum will be available by April 2008 and will be made available on the UNAIDS and WFMH websites.

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