Mental Health Interventions for People Living With HIV

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Introduction

Since its outbreak in the 1980’s, HIV has resulted in immense global and individual health consequences, and in some African countries, it remains the leading cause of death. The introduction and improved availability of ART (antiretroviral treatment) in recent years, has resulted in fewer people succumbing to the fatal effects of the virus . With more people surviving, the prevalence of HIV has increased significantly. This brings forth the challenge of ensuring that PLWH (people living with HIV) are living good quality, functional lives. Both the effects of the virus and the side effects of ART can have detrimental effects on PLWH’s physical health (pain and energy levels) and mental health (depression and anxiety).

Relationship Between HIV and Mental Health

One of the prominent elements contributing to impaired quality of life of PLWH is poor mental health. Mental health problems, such as depression and anxiety, are very common among PLWH. The prevalence rate of depression and mood disorders among PLWH  is approximately 33% and the prevalence rate of anxiety disorders is about 20%. This is much higher than the global prevalence of the general population which is 4.7%. It is therefore clear that having HIV poses an increased risk of developing mental health disorders.

Mental health problems have been recognised as a key factor in affecting HIV treatment outcomes. Poor mental health has been shown to negatively affect HIV disease progression as well as adherence to ART. Those who report needing mental health care, but do not receive it, are more likely to not adhere to their ART medication compared to those who do receive mental health care support. Furthermore, evidence also suggests that poor viral suppression (as a result of poor ART adherence) may again lead to an increased risk of mental health problems. High levels of stress and depression have also been associated with poor disease parameters (reduced CD4 and increased viral load) - This could be related to associated poor ART adherence, or attributed to the physiological effects of stress and depression .

“PLWH and depression are 42% less likely to achieve good ART adherence, more likely to develop virologic failure and are more likely to have HIV progression, independent of ART adherence, than those without depression”

Mental health in PLWH can be influenced by various biopsychosocial factors, including:

• Isolation
• Stigma
• Discrimination
• Low socio-economic status
• Lack of support
• Disease-related pain
• Neurological damage caused by opportunistic infections
• Neuropsychiatric side effects of some ART (Zidovudine and Abacavir have been associated with mood changes).
• Food insecurity and poverty.
• Lack of purpose in society .

The World Health Organisation (WHO) describes the concept of quality of life as: “an individual’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns”. It is clear that addressing mental health in PLWH should be a priority - not only to improve psychological factors but in order to improve medication adherence and physical health - in order to ultimately improve the quality of life of PLWH.

Mental Health Intervention for PLWH

The prevalence of PLWH is much higher in low-mid income settings, but there are significant barriers to providing mental health services in these countries, mostly since there is a lack of trained mental health workers (2). In Sub-saharan Africa (SSA), there is one mental health professional per 70 000 people (9). Furthermore, time spent in therapy could be time spent for income generation and could therefore result in poor adherence in low-mid income countries (9). Thus, the very therapies that are deemed efficacious for HIV-positive populations in resource-rich settings may not be feasible to deliver in SSA settings. It is possible that group based interventions could have a better acceptability than traditional individual mental health therapies (11).

Pharmacological interventions

The majority of PLWH, live in low to middle-income countries. It is therefore important to consider results from studies that were done in these settings. In studies conducted in Uganda, full adherence to medication was low (56%) and in Malawi treatment was hindered by low stock of antidepressants nationwide. In addition, the evidence to support the use of antidepressants is inconclusive and it might not have many benefits over psychological interventions alone. Considering the potential issues with adherence and the lack of strong evidence, pharmacological interventions might not be the most practical or cost-effective treatment in PLWH.

Psychotherapeutic interventions

Adherence to psychotherapeutic interventions is also important to consider, as this will have an effect on the effectiveness of the treatment - It is therefore important to ensure that the interventions are tailored to the cultural context of the target population.

The approach used and the level of qualification of the therapist does not seem to be associated with intervention effectiveness in low-mid income settings , it can therefore be argued that a group format delivered by lay healthcare workers could be an effective, sustainable and accessible option in poorer countries. Programmes aimed at training lay health workers in counselling will be important in narrowing the mental health treatment gap in low- and mid income (LMICs) countries.

Every person’s context will be different, and it’s important to involve the community in the intervention design to ensure good adherence (5). Some studies have included financial incentives and cultural rituals, others involved spiritual activities during therapy (5). Recent research indicates that accommodating patient preference in mental health services maximizes treatment uptake and reduces financial costs of premature dropout and disengagement (5).

The evidence seems to suggest that, when it comes to psychotherapy, it is more important to consider what is available and culturally appropriate, rather than focusing on the content and specifics of the therapeutic method/approach.

Individual therapy

There is good evidence to support the effectiveness of psychotherapy for depression in PLWH in both low and high resource settings . The ‘active ingredients of psychotherapy that were associated with enhanced effectiveness in research studies were:

• Cognitive restructuring
• Positive coping skills
• Venting (sharing personal problems)
• Social support
• Behaviour activation.

Group therapy

Group support psychotherapy sessions which are suited to a community, have been shown to be very effective in achieving long lasting reduction in depression in PLWH (5). These group therapy sessions should involve behavioral psychotherapeutic methods (education, sharing, coping skills etc.), as well as training in basic livelihood  skills and planning livelihood activities (11). A major advantage of a well designed group intervention is that it does not require ongoing input from expert mental health practitioners. Instead, primary healthcare workers in rural health centers are trained to deliver the sessions. Attending group sessions has also been shown to improve clinical health parameters. This could partially be attributed to associated improved adherence to ART with subsequent suppression of the HIV viral load. This means that affected individuals are less likely to transmit the virus to others (11). It is also more cost effective than group HIV education-only sessions (11).

Social and behavioral interventions

Interventions such as yoga, meditation, mindfulness, symptoms management strategies and education, have been shown to be effective in addressing mental health QOL in PLWH, but the quality of evidence is unfortunately poor (12).

There is a known relationship between poverty and mental health, and a research has found a correlation between food security and depression in PLWH in sub-saharan africa (9) . Therefore livelihood programs that aim to improve food security could have potential. A study has shown that providing food hand-outs has little effect on mental health (9). Therefore the focus should be on interventions that focus on building skills and capital over time, with the aim of restoring productive routines and reducing financial concerns (9). One study performed in Kenya showed that improved food security resulted in reduced anxiety and depressive symptoms in PLWH (9). These interventions have the benefit of reducing financial stress, but also serves as a means to restore purpose and reduce rumination, as well as improved self-efficacy (9). To read more about the Shamba Maisha program that was used, see the article by Hatcher et al.

“For those who are stigmatised and marginalized, as those with food insecurity and HIV often are, livelihood interventions can contribute powerfully to social reintegration and reversal of status loss —which may be even more important than short term gains in food security” (9).

Physical activity and exercise interventions

The benefits of exercise on the physical health of PLWH are well established and exercise has therefore been advocated for as an important treatment component for PLWH. Various studies have now shown that exercise (aerobic and resistance exercise) can also have positive effects on mental health in PLWH (6) (13) (14). The low cost and ease of implementation of exercise interventions, make it a very feasible treatment approach in all settings (8).

Integrated approach

PLWH often have multiple physical barriers to well-being. Pain and lack of energy, as well as recurrent infections, can have a significant influence on mental well-being (2). Combined medical and psychological interventions are therefore advisable to ensure that physical symptoms do not continue to contribute to poor mental health. Collaboration between health care providers or integrated multidisciplinary facilities could assist in addressing the complexity of factors involved in the well-being of PLWH (14).

Global Health Considerations

The highest burden of HIV depression is found in Africa [3], where lack of resources and infrastructure poses challenges to mental health interventions. Ironically most of the mental health intervention research thus far for this population group has been done in high resource settings. It is therefore important for further research to be focused on low to mid income settings, as well as on interventions that are cost effective and culturally appropriate.

In 2018, UNAIDS made it clear that HIV and mental health is a topic that needs more attention in order to address the HIV epidemic (5). Mental health conditions can vary from mild to severe, and therefore policies should not only be focused on treatment interventions, but also on promotion and preventive strategies (20).

Conclusion

One can almost argue that access to mental health treatment and rehabilitation for PLWH, should be just as important as access to ART. PLWH have the right to improved quality of life, and addressing mental health concerns should therefore be a very important consideration. Physiotherapists have an important role to play in providing effective, holistic interventions for PLWH.