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Barriers to mental healthcare and treatment for people living with HIV in the Asia-Pacific

2018; International AIDS Society; Volume: 21; Issue: 10 Linguagem: Inglês

10.1002/jia2.25189

1758-2652

Annette H. Sohn, Jeremy Ross, Milton L. Wainberg,

HIV, Drug Use, Sexual Risk

Mental illness is a leading cause of disability in South East Asia among those 15 to 49 years of age, with over 7.6 million disability-adjusted life-years lost in 2016 alone 1. Regional studies have found that as much as 40% of adults attending outpatient HIV clinics in Asia-Pacific countries have depression 2, 3. Concomitant mental illness is associated with late antiretroviral therapy (ART) initiation and lack of timely viral suppression in people living with HIV (PLHIV) 4, 5. A key intervention to overcome the substantial human resource limitations for mental healthcare for PLHIV in the region is to train non-mental health specialists to deliver basic psychotherapeutic interventions with expert supervision. An example of this is the WHO's Mental Health Gap Action Programme (mhGAP), which has developed tools to accelerate task-shifting in low- and middle-income country settings (LMICs) 11. This includes training to screen, diagnose and treat common mental illnesses through a standardized platform. While there are efforts to implement mhGAP in primary care settings in the region, including in Cambodia, Malaysia and the Philippines, the tools are rarely used in HIV care. There is substantial potential to improve access to mental healthcare for PLHIV by expanding the use of these interventions. In addition, research should be conducted within real-world care settings to determine optimal strategies to diagnose and treat those in need as well as quantify the impact on adherence, retention and mortality for mental healthcare interventions. Identification and evaluation of optimal implementation strategies to scale and sustain integrated HIV and mental healthcare could provide the data needed to justify proactive policies and the allocation of limited health resources. Implementation science offers a platform particularly well-suited to conduct research around the intersection of HIV and mental health, and can address complex questions related to the adoption, adaptation, integration, scale-up and sustainability of evidence-based practices, as well as monitoring and evaluating of outcomes at the patient, provider and system levels. Evidence-based tools and treatments developed in high-income countries must be “translated” across cultures, which requires more than linguistic adaptation in order to balance fidelity (to the original intervention) and fit (for a novel context) to achieve the desired outcomes of the interventions 12, 13. Mental health implementation science acknowledges variations in local knowledge, norms, attitudes and beliefs about mental illness, including stigma, which would be particularly useful in the Asia-Pacific region where there is extensive cultural, religious and linguistic variation. Central to these potential solutions for bridging the gaps between HIV and mental health is public health leadership and the political will behind it to prioritize mental healthcare within HIV programmes. As external HIV funding declines to Asia-Pacific LMICs 8, national programmes are increasingly focused on achieving the UNAIDS 90-90-90 targets. However, with only 53% treatment coverage in the region, national programmes already face major challenges in scaling up. Calls for more comprehensive care for non-communicable diseases will not be met without stronger advocacy and domestic and international donor support for mental healthcare. While countries in the Asia-Pacific continue to make progress with HIV testing and treatment scale-up, we need a clear way forward to address mental health challenges among PLHIV. Access to potent antiretroviral medicines and laboratory monitoring alone will not solve these problems, which pose very real threats to adherence, retention and quality of life. Delivering sustainable and cost-effective mental health services and addressing human resource, data and policy gaps are essential to address the intersection between HIV and mental illness, and will help maintain the public health gains made in controlling regional HIV epidemics. AHS has received travel and research support to her institution from ViiV Healthcare. AHS and MLW developed the idea for and drafted the Viewpoint. All authors participated in research think tanks where ideas presented in the Viewpoint were discussed, and revised and approved the text. The authors thank the following experts who supported the TREAT Asia think tanks on adolescent mental health and HIV in January 2017 and on depression in adults living with HIV in January 2018: Vitharon Boon-Yasidi, Iris Chan, Fran Cournos, Jackie Hoare, Isabel Medgar, Kay Malee, Claude Mellins, Oui Saisaengjan, and Warren Ng. The research think tanks were supported by ViiV Healthcare and the US National Institutes of Health's National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Cancer Institute, National Institute on Mental Health and National Institute of Drug Abuse as part of the International Epidemiology Databases to Evaluate AIDS (IeDEA; U01AI069907). The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of any of the institutions mentioned above.