Opportunities and challenges to integrating mental health into HIV programs in a low- and middle-income country: insights from the Nigeria implementation science Alliance

Abstract

Background In Nigeria, there is an estimated 1.9 million people living with HIV (PLHIV), 53% of whom utilize HIV care and services. With decreasing HIV-related deaths and increasing new infections, HIV with its associated comorbidities continue to be a key public health challenge in Nigeria. Untreated, comorbid mental disorders are a critical but potentially modifiable determinant of optimal HIV treatment outcomes. This study aimed to identify the challenges and opportunities related to integrating mental health care into existing HIV programs in Nigeria. Method Attendees at the Nigeria Implementation Science Alliance (NISA)‘s 2019 conference participated in nominal group technique (NGT) exercise informed by the “Exploration, Preparation, Implementation, and Sustainment (EPIS)” framework. The NGT process was conducted among the nominal groups in two major sessions of 30-min phases followed by a 30-min plenary session. Data analysis proceeded in four steps: transcription, collation, theming and content analysis. Results The two major theoretical themes from the study were – opportunities and challenges of integrating mental health treatment into HIV services. Three sub-themes emerged on opportunities: building on health care facilities for HIV services (screening, counseling, task-sharing monitoring and evaluation frameworks), utilizing existing human resources or workforce in HIV programs (in-service training and including mental health in education curriculum) and the role of social and cultural structures (leveraging existing community, traditional and faith-based infrastructures). Four sub-themes emerged for challenges: double burden of stigma and the problems of early detection (HIV and mental health stigma, lack of awareness), existing policy gaps and structural challenges (fragmented health system), limited human resources for mental health care in Nigeria (knowledge gap and burnout) and dearth of data/evidence for planning and action (research gaps). Conclusions Potential for integrating treatments for mental disorders into HIV programs and services exist in Nigeria. These include opportunities for clinicians’ training and capacity building as well as community partnerships. Multiple barriers and challenges such as stigma, policy and research gaps would need to be addressed to leverage these opportunities. Our findings serve as a useful guide for government agencies, policy makers and research organizations to address co-morbid mental disorders among PLHIV in Nigeria.

Mapping evidence on barriers to and facilitators of diagnosing noncommunicable diseases among people living with human immunodeficiency virus in low- and middle-income countries in Africa: A scoping review

“…Twenty-eight articles in the review identified barriers to diagnosing NCDs (hypertension and diabetes). 14 , 15 , 20 , 35 – 61 The included studies reported barriers to and facilitators of diagnosing depression among PLWH. 42 , 50 , 62 – 73 Two studies reported both NCDs and depression.…”

Provision of HIV services to psychiatric inpatients in Botswana: Challenges and recommendations

“…26 Several studies have reported various challenges to integrate HIV and mental healthcare. 27,28 Among the challenges are inadequate human and financial resources, dearth of data or evidencebased practices, double burden of stigma, structural challenges and a lack of training on HIV services among psychiatric health providers. 27,28,29,30 Despite these challenges, there is evidence of successful integration of HIV and psychiatric services.…”

“…27,28 Among the challenges are inadequate human and financial resources, dearth of data or evidencebased practices, double burden of stigma, structural challenges and a lack of training on HIV services among psychiatric health providers. 27,28,29,30 Despite these challenges, there is evidence of successful integration of HIV and psychiatric services. Currently, in Rwanda, psychiatric patients receive routine screening and counselling for HIV and within-facility initiation for ART for those testing positive.…”

Depression-Mediating Pathways From Household Adversity to Antiretroviral Therapy Nonadherence Among Children and Adolescents Living With HIV in Zambia: A Structural Equation Modeling Approach

“…14,15 Limited capacities and resources to identify, diagnose, and treat depressive symptoms within health systems also constrain opportunities to deliver mental health care and supportive services. 15 Oftcited efforts to address psychological distress among CALWH involve family-based interventions (ie, caregiver strengthening and parent-child communication), frequently facilitated by lay service providers such as peers and community health workers. 16 Specialized mental health care and treatment, however, may be needed for CALWH exhibiting more severe manifestations of psychological distress.…”

“…Stigma related to mental health disorders can demotivate care-seeking and even interfere with caregiver recognition of psychological distress in children and adolescents. 14,15 Limited capacities and resources to identify, diagnose, and treat depressive symptoms within health systems also constrain opportunities to deliver mental health care and supportive services. 15 Oftcited efforts to address psychological distress among CALWH involve family-based interventions (ie, caregiver strengthening and parent-child communication), frequently facilitated by lay service providers such as peers and community health workers.…”