Brief Report: Task-Shifting “Gold Standard” Clinical Assessment and Safety Planning for Suicide Risk Among People Living With HIV: A Feasibility and Fidelity Evaluation in Tanzania

Abstract

Background: Suicide is a leading cause of death among people living with HIV (PLWH) worldwide, with suicide deaths occurring twice as frequently among PLWH than among the general public. In Tanzania, resources for mental health care are sorely lacking, with 55 psychiatrists and psychologists providing treatment for 60 million people. In light of this shortage, nonspecialists play a crucial role. The objective of this study was to assess feasibility of implementing task-shifted screening, assessment, and safety planning for suicide risk among PLWH. Setting: Two adult HIV clinics in Kilimanjaro, Tanzania. Methods: Registered professional nurses in the HIV clinics were trained to administer brief screening of suicidal ideation in the past month. Patients experiencing suicidal ideation were referred to bachelor's-level counselors for further assessment and safety planning, supervised by specialist providers who reviewed audio recordings for quality assurance. Results: During 180 days of implementation, nurses screened patients attending 2745 HIV appointments. Sixty-one (2.2%) endorsed suicidal ideation and were linked to further assessment and safety planning. We cross-checked screening with clinic attendance logs on 7 random days and found high fidelity to screening (206 of 228 screened, 90%). Quality assurance ratings demonstrated key assessment pieces were consistently completed (mean = 9.3/10 possible), with “Good” to “Excellent” counseling skills (mean = 23.7/28) and “Good” to “Excellent” quality (mean = 17.1/20), including appropriate referral for higher levels of care. Conclusions: Brief screening can be implemented and paired with task-shifted counseling to facilitate high-quality assessment of suicide risk. This model shows excellent potential to extend mental health services for PLWH in low-resource settings.

Challenges and opportunities for improving mental health care and preventing suicide among people living with HIV: Perspectives of mental health professionals in Tanzania

“…Our interviews highlight the need for investment in mental health infrastructure, including additional facilities and an increased workforce, across Tanzania to improve the existing system [23]. Improved screening within routine care (e.g., HIV clinics) and a more streamlined referral process can improve identification of individuals with mental health challenges and PLOS GLOBAL PUBLIC HEALTH connect them to needed care [20,28]. The cost of care, which is a limiting factor for many individuals with mental health challenges, can be addressed through subsidized treatment and increased access to health insurance [46].…”

“…There was support from the mental health workers interviewed for exploration of telehealth as well as excitement about its potential to improve access to mental health care in this setting; however, their feedback highlights the need to attend to concerns about confidentiality, ease of use of technology, and human resource capacity to prevent additional burden on already overtaxed health systems. Identifying provider suggestions and potential challenges during the formative phase of intervention development was critical to developing a responsive, feasible, and sustainable intervention model and protocol for piloting the intervention [29]; for example, the use of WhatsApp, a platform that is already familiar and in wide use in this setting, can reduce the burden of needing to learn new technology, and the task shifting model of screening and referral piloted by our team has demonstrated early indications of a promising approach [28].…”

“…In northern Tanzania, HIV care is provided free of charge with support from Tanzania's National AIDS Control Program [27]; however, mental health screening and treatment is generally not incorporated into HIV care [25,28]. Despite the successful decentralization of HIV care to many smaller clinics in Tanzania, mental health care in the country remains largely centralized at major hospitals, where suicide prevention has rarely been prioritized [22].…”

Validation of a culturally sensitive, Swahili-translated instrument to assess suicide risk among adults living with HIV in Tanzania

“…However, there is an immediate need to develop suicide prevention interventions that can utilize currently available resources efficiently while rapidly developing new services. This may also include enhanced mental health education in nursing and allied health professions, task sharing of treatment with non-specialists, and utilizing technological advancements such as telehealth to increase treatment capacity (Knettel et al, 2023a). It is important, however, to ensure that new services are developed while considering patients' safety, the evidence base of the treatments provided, and culturally informed development or adaptation of treatment approaches (Perera et al, 2020;Spanhel et al, 2021).…”