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Mental Health and HIV/AIDS Programs in Africa
By John R. Anderson, PhD
Dr. John Anderson, Senior Director of APA’s Office on AIDS, was recently in South Africa as part of the World Federation for Mental Health’s Expert forum meeting on advocacy for mental health and AIDS issues. This is his report.
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 (WFMH) expert forum convened in Cape Town, South Africa during the last week in January 2008. Participants described how poorly trained providers and huge gaps in the capacities of service delivery systems lead to undue suffering, a loss of quality of life, and poor engagement of, and adherence to, HIV prevention, treatment and AIDS care programs.
Dr. John Anderson, Senior Director of the American Psychological Association Office on AIDS, along with 23 other 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 caregivers, 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 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. Psychologist and World Health Organization (WHO) consultant Melvyn Freeman described a study in Zambia that showed 85% of pregnant HIV+ women had episodes of major depression with suicidal ideation as well as other studies in East and Southern Africa revealing dramatically increased depression and suicide among AIDS orphans.
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, including 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, disseminate best practices and tools, and further mobilize and coordinate organizations committed to greater collaboration between the fields of mental health and HIV/AIDS.
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 programs.
UNAIDS Senior Advocacy Advisor for the East and Southern Africa Regions, 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, scaling-up and increased collaboration. Although many aspects of HIV-related mental health needs have been addressed at the community level for years, the needs of people living with HIV as well as those with an increased care burden are often inadequately addressed. Relevant program remain under resourced and they could benefit from the infusion of evidence-based practice models as well as 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 providers and orphans and vulnerable children. She also highlighted the need for interventions targeting both mental health and prevention for young people engaging in substance use. The need for increased integration of the needs and voices of 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 caregivers - including the many caregivers who themselves are HIV positive and children who are the head of 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 mental health services and training non-professional caregivers to provide services in the community. Professional-level staff are rare and under a great deal of pressure to deal with hundreds of patients in a short space of time.
Julian Sturgeon, National Manager of the Treatment Action Campaign (TAC) in South Africa, highlighted the work of the organization's treatment literacy program run by trained Treatment Literacy Practitioners who utilize well-designed training materials to ensure optimum adherence to treatment among people living with HIV. Julian suggested TAC materials could be easily adapted to include mental health information and used across the Africa region.
June Koinange, President of the Kenya Psychological Association, expressed the need to train key community leaders who can enhance community mobilization related to AIDS and mental health. "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 programs was raised as an important roll out strategy by psychologist 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 counseling offered to support different aspects of the AIDS response including HIV testing, treatment and care. Psychologist Kevin Kelly, Director of the Centre for AIDS Development, Research and Evaluation, recommended that the WFMH initiative support increased and ongoing professionalization of counseling including an appropriate qualifications framework.
Sheila Ndyanabangi, Principal Medical Officer for Mental Health in Uganda's Ministry of Health, raised the importance of addressing mental health issues in the context of providing information to HIV+ patients about treatment options. She proposed the development of practical training materials based on evidence-based approaches adapted to African settings.
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. He reminded participants that mental health principles and approaches are already incorporated into many AIDS programs. Connie Wambui Mureithi, Coordinator of the Eastern Africa Region of the Society of Women and AIDS in Africa, also advocated that in moving forward, the WFMH initiative should expand on quality services that are already being delivered.
Rita Thom, of the University of Witwatersrand Division of Psychiatry, suggested possible future collaboration on a joint HIV and mental health initiative 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 best practices were presented from a number of countries including Kenya, Swaziland, Tanzania and Zambia and also from a well-integrated project based in Goa on the west coast of India. Following the presentations Psychologist Arvin Bhana of the Human Sciences Reasearch Council, challenged participants to ensure that a key focus of the WFMH will 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 programs to strengthen the many community based initiatives already focused on psychosocial 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 initiative will seek to mobilize further interest at the African Psychiatric Conference to be held in Ghana in April 2008. Additionally, WFMH plans to 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.
Dr. Anderson will be working with the leadership of WFMH to mobilize psychologists for this effort and to ensure that best practices from psychological science and practice inform this well-conceived international effort. For further information see the World Federation for Mental Health Website at www.wfmh.org or email firstname.lastname@example.org. A full report on the expert forum will be available by April 2008 and will be made available on the APA, UNAIDS and WFMH websites.