Submitted by: Melissa Sharer AIDSTAR-One Senior Care and Support Officer, John Snow, Inc.

AIDSTAR-One is funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID’s Office of HIV/AIDS, and provides rapid technical assistance to USAID and U.S. Government (USG) country teams to build effective, well-managed, and sustainable HIV and AIDS programs, and promotes new leadership in the global campaign against HIV.

“First we need ARVs, second is Duong Sinh TuNa, third is psychosocial support,” said an HIV-positive female client at an HIV clinic in Van Don, Vietnam. Her spontaneous response to a question about the needs of people living with HIV (PLHIV) includes a double dose of mental health care and support. Duong Sinh TuNa is a rhythmic poem recited during relaxation and stretching exercises hosted at the clinic she attends. It reads in part: “Breathe, meditate, relax, exercise, think positively…Healthy minds and clearer thinking help recovery.”

This client knows what she’s talking about. An individual’s well-being underpins everything she or he does. Emotional health facilitates opportunities to form relationships, to love, to work, allowing a person to continue making choices that support good physical health. The World Health Organization defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to his or her community,” a definition that should inform all programs and policies targeting individuals living with HIV.

Mental health services are thus critical to a continuum-of-care approach for people living with HIV (PLHIV).  A recent meta-analysis looking at depression and adherence shows a consistent relationship between depression and HIV treatment non-adherence (Gonzalez et al. 2011). Estimated rates of depression among PLHIV soar as high as 72 percent in resource-constrained countries (Adewuya et al. 2007), which threatens the consistent use of the antiretroviral therapy (ART) that keeps them alive.

Although treatment is now widely available and PLHIV are able to live normal and active lives for many years, their mental health needs are often overlooked in care, treatment, and support programs. This has profound effects not only on quality of life, ART adherence, and mortality, but also on retention in care, immunological status, symptom severity, and morbidity, all of which combine to influence HIV progression. Clearly, addressing the mental health of PLHIV is central to a comprehensive approach that meets their holistic needs.

For two very different countries, the answer has been to combine mental health and existing health services. In Vietnam, a  program funded by PEPFAR through USAID and implemented by FHI360 integrates mental health for PLHIV into HIV care and treatment services. HIV providers learn to screen for anxiety and depression so they can provide care and referrals for additional treatment and support. Vietnam works from a strengths-based positive perspective, using yoga, nutrition, medication, counseling, behavioral, and pharmacologic treatment to improve well-being. In Uganda, the special mental health needs of PLHIV are integrated into existing mental health services. Under a program, implemented by the Peter C. Alderman Foundation (PCAF), mental health providers (social workers, psychiatrists, psychiatric nurses, and psychologists) receive HIV care training, which gives them the skills to refer and accompany PLHIV to HIV services. This program greatly improves quality of life for PLHIV, their families, and their communities.

The lessons learned from the two programs are numerous. Both follow strong programming practices that are used worldwide: collecting data to improve services, maintaining quality assurance, supporting country ownership, and building sustainability. Both have also developed solid referral and case management systems that are affordable, context-sensitive, and effective at responding to the complex needs of PLHIV.

And both programs also take seriously the key lesson of the Duong Sinh TuNa:  In addition to pharmacological treatment, support PLHIV holistically with such interventions as family therapy, nutrition, meditation, yoga, peer groups, and cognitive therapy.

Thanks to better access to antiretrovirals, PLHIV are living longer — lives of complexity, full of tough and joyful moments, with opportunities for happiness ideally outnumbering hardships. To improve and prolong those lives, global HIV programs and policies must learn to care for individuals in their entirety.

Adewuya, A.O. et al. 2007. Psychiatric disorders among the HIV-positive population in Nigeria: a control study. Journal of Psycho­somatic Research 63(2): 203-6.

Gonzalez, J. et al. 2011. Depression and HIV/AIDS Treatment Nonadherence: A Review and Meta-analysis. Journal of Acquired Immune Deficiency Syndromes 58(2): 181-187.