Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program

Michael Udedi, Melissa A Stockton, Kazione Kulisewa, Mina C Hosseinipour, Bradley N Gaynes, Steven M Mphonda, Beatrice Matanje Mwagomba, Alick C Mazenga, Brian W Pence, Michael Udedi, Melissa A Stockton, Kazione Kulisewa, Mina C Hosseinipour, Bradley N Gaynes, Steven M Mphonda, Beatrice Matanje Mwagomba, Alick C Mazenga, Brian W Pence

Abstract

Background: In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation.

Methods: We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program's effect on patients' depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned.

Results: We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care.

Conclusions: This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting.

Trial registration: ClinicalTrials.gov ID [ NCT03555669 ]. Retrospectively registered on 13 June 2018.

Keywords: Depression; HIV/AIDS; Implementation science; Integration; Malawi; Mental health; Service delivery; Sub-Saharan Africa.

Conflict of interest statement

Ethics approval and consent to participate

The study received ethical approval from Malawi MOH’s National Health Science Research Committee (NHSRC) institutional review board (IRB) and the UNC IRB. All participants were provided with the necessary information. Written informed consent was given prior to data abstraction.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Evaluation Design
Fig. 2
Fig. 2
Implementation Timeline

References

    1. Kauye F, Jenkins R, Rahman A. Training primary health care workers in mental health and its impact on diagnoses of common mental disorders in primary care of a developing country, Malawi: a cluster-randomized controlled trial. Psychol Med. 2014;44(03):657–666. doi: 10.1017/S0033291713001141.
    1. Kim MH, Mazenga AC, Devandra A, Ahmed S, Kazembe PN, Yu X, Nguyen C, Sharp C. Prevalence of depression and validation of the Beck depression inventory-II and the Children's depression inventory-short amongst HIV-positive adolescents in Malawi. J Int AIDS Soc. 2014;17(1)
    1. Malava JK, Lancaster KE, Hosseinipour MC, Rosenberg NE, O’Donnell JK, Kauye F, Mbirimtengerenji N, Chaweza T, Tweya H, Phiri S et al: Prevalence and correlates of probable depression diagnosis and suicidality among patients receiving HIV care in Lilongwe, Malawi. AIDS patient care and STDs Under Review.
    1. Government of Malawi Ministry of Health . Malawi Health Sector Strategic Plan 2011–2016: Moving towards equity and quality. Lilongwe, Malawi: Government of Malawi Ministry of Health; 2011.
    1. Lupafya PC, Mwagomba BLM, Hosig K, Maseko LM, Chimbali H. Implementation of policies and strategies for control of noncommunicable diseases in Malawi: challenges and opportunities. Health Educ Behav. 2016;43(1_suppl):64S–69S. doi: 10.1177/1090198115614313.
    1. Government of Malawi Ministry of Health . Malawi Health Sector Strategic Plan II 2017–2022: Towards Universal Health Coverage. Lilongwe, Malawi: Government of Malawi Ministry of Health; 2017.
    1. Government of Malawi Ministry of Health . The National Action Plan for NCDs and Mental Health (2012-2016) Lilongwe, Malawi: Government of Malawi Ministry of Health; 2013.
    1. Kauye F, Chiwandira C, Wright J, Common S, Phiri M, Mafuta C, Senganimalunje L, Udedi M. Increasing the capacity of health surveillance assistants in community mental health care in a developing country Malawi. Malawi Med J. 2011;23(3):85–88.
    1. Wright J, Chiwandira C. Building capacity for community mental health care in rural Malawi: findings from a district-wide task-sharing intervention with village-based health workers. Int J Soc Psychiatry. 2016;62(6):589–596. doi: 10.1177/0020764016657112.
    1. Wright J, Common S, Kauye F, Chiwandira C. Integrating community mental health within primary care in southern Malawi: a pilot educational intervention to enhance the role of health surveillance assistants. Int J Soc Psychiatry. 2014;60(2):155–161. doi: 10.1177/0020764012471924.
    1. Fox MP, Rosen S. Retention of adult patients on antiretroviral therapy in low- and middle-income countries: systematic review and meta-analysis 2008-2013. J Acquir Immune Defic Syndr. 2015;69(1):98–108. doi: 10.1097/QAI.0000000000000553.
    1. Rasschaert F, Koole O, Zachariah R, Lynen L, Manzi M, Van Damme W. Short and long term retention in antiretroviral care in health facilities in rural Malawi and Zimbabwe. BMC Health Serv Res. 2012;12:444. doi: 10.1186/1472-6963-12-444.
    1. Massaquoi M, Zachariah R, Manzi M, Pasulani O, Misindi D, Mwagomba B, Bauernfeind A, Harries AD. Patient retention and attrition on antiretroviral treatment at district level in rural Malawi. Trans R Soc Trop Med Hyg. 2009;103(6):594–600. doi: 10.1016/j.trstmh.2009.02.012.
    1. Nakimuli-Mpungu E, Bass JK, Alexandre P, Mills EJ, Musisi S, Ram M, Katabira E, Nachega JB. Depression, alcohol use and adherence to antiretroviral therapy in sub-Saharan Africa: a systematic review. AIDS Behav. 2011;
    1. Smillie K, Van Borek N, van der Kop ML, Lukhwaro A, Li N, Karanja S, Patel AR, Ojakaa D, Lester RT. Mobile health for early retention in HIV care: a qualitative study in Kenya (WelTel retain) Afr J AIDS Res. 2014;13(4):331–338. doi: 10.2989/16085906.2014.961939.
    1. Franke MF, Kaigamba F, Socci AR, Hakizamungu M, Patel A, Bagiruwigize E, Niyigena P, Walker KD, Epino H, Binagwaho A, et al. Improved retention associated with community-based accompaniment for antiretroviral therapy delivery in rural Rwanda. Clin Infect Dis. 2013;56(9):1319–1326. doi: 10.1093/cid/cis1193.
    1. Pence BW, Miller WC, Gaynes BN, Eron JJJ. Psychiatric illness and virologic response in patients initiating highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2007;44(2):159–166. doi: 10.1097/QAI.0b013e31802c2f51.
    1. Kidia K, Machando D, Bere T, Macpherson K, Nyamayaro P, Potter L, Makadzange T, Munjoma R, Marufu M, Araya R, et al. 'I was thinking too much': experiences of HIV-positive adults with common mental disorders and poor adherence to antiretroviral therapy in Zimbabwe. Tropical Med Int Health. 2015;20(7):903–913. doi: 10.1111/tmi.12502.
    1. Martinez P, Andia I, Emenyonu N, Hahn JA, Hauff E, Pepper L, Bangsberg DR. Alcohol use, depressive symptoms and the receipt of antiretroviral therapy in Southwest Uganda. AIDS Behav. 2008;12(4):605–612. doi: 10.1007/s10461-007-9312-x.
    1. Gonzalez JS, Batchelder AW, Psaros C, Safren SA. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011;58(2):181–7.
    1. Leserman J, Pence BW, Whetten K, Mugavero MJ, Thielman NM, Swartz MS, Stangl D. Relation of lifetime trauma and depressive symptoms to mortality in HIV. Am J Psychiatry. 2007;164(11):1707–1713. doi: 10.1176/appi.ajp.2007.06111775.
    1. Leserman J. Role of depression, stress, and trauma in HIV disease progression. Psychosom Med. 2008;70(5):539–545. doi: 10.1097/PSY.0b013e3181777a5f.
    1. Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum EE, Schuman P, Boland RJ, Moore J. Mortality, CD4 cell count decline, and depressive symptoms among HIV-seropositive women: longitudinal analysis from the HIV epidemiology research study. JAMA. 2001;285(11):1466–1474. doi: 10.1001/jama.285.11.1466.
    1. Gaynes BN, West SL, Ford CA, Frame P, Klein J, Lohr KN. Screening for suicide risk in adults: a summary of the evidence for the U.S. preventive services task force. Ann Intern Med. 2004;140(10):822–835. doi: 10.7326/0003-4819-140-10-200405180-00015.
    1. Stoudemire A, Frank R, Hedemark N, Kamlet M, Blazer D. The economic burden of depression. Gen Hosp Psychiatry. 1986;8(6):387–394. doi: 10.1016/0163-8343(86)90018-6.
    1. Angst J, Angst F, Stassen HH. Suicide risk in patients with major depressive disorder. J Clin Psychiatry. 1999;60(Suppl 2):57–62.
    1. Ramirez-Avila L, Regan S, Giddy J, Chetty S, Ross D, Katz JN, Freedberg KA, Walensky RP, Losina E, Bassett IV. Depressive symptoms and their impact on health-seeking behaviors in newly-diagnosed HIV-infected patients in Durban, South Africa. AIDS Behav. 2012;16(8):2226–2235. doi: 10.1007/s10461-012-0160-y.
    1. Rane MS, Hong T, Govere S, Thulare H, Moosa M-Y, Celum C, Drain PK. Depression and anxiety as risk factors for delayed care-seeking behavior in human immunodeficiency virus–infected individuals in South Africa. Clin Infect Dis. 2018; ciy309
    1. Turan B, Stringer KL, Onono M, Bukusi EA, Weiser SD, Cohen CR, Turan JM. Linkage to HIV care, postpartum depression, and HIV-related stigma in newly diagnosed pregnant women living with HIV in Kenya: a longitudinal observational study. BMC Pregnancy Childbirth. 2014;14(1):400. doi: 10.1186/s12884-014-0400-4.
    1. Chuah FLH, Haldane VE, Cervero-Liceras F, Ong SE, Sigfrid LA, Murphy G, Watt N, Balabanova D, Hogarth S, Maimaris W. Interventions and approaches to integrating HIV and mental health services: a systematic review. Health Policy Plan. 2017;32(suppl_4):iv27–iv47. doi: 10.1093/heapol/czw169.
    1. World Health Organization . Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach in., second edn. Geneva, Switzerland: World Health Organization; 2016.
    1. World Health Organization . Integrating mental health into primary care : a global perspective. Geneva, Switzerland: World Health Organization and World Organization of Family Doctors (Wonca); 2008.
    1. Lofgren SM, Nakasujja N, Boulware DR. Systematic review of interventions for depression for people living with HIV in Africa. AIDS Behav. 2018;22(1):1–8. doi: 10.1007/s10461-017-1906-3.
    1. Petersen I, Hancock JH, Bhana A, Govender K. A group-based counselling intervention for depression comorbid with HIV/AIDS using a task shifting approach in South Africa: a randomized controlled pilot study. J Affect Disord. 2014;158:78–84. doi: 10.1016/j.jad.2014.02.013.
    1. Chibanda D, Mesu P, Kajawu L, Cowan F, Araya R, Abas MA. Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health. 2011;11(1):828. doi: 10.1186/1471-2458-11-828.
    1. Gaynes BN, Pence BW, Atashili J, O’Donnell JK, Njamnshi AK, Tabenyang ME, Arrey CK, Whetten R, Whetten K, Ndumbe P. Changes in HIV outcomes following depression care in a resource-limited setting: results from a pilot study in Bamenda, Cameroon. PLoS One. 2015;10(10):e0140001. doi: 10.1371/journal.pone.0140001.
    1. Pence BW, Gaynes BN, Atashili J, O'Donnell JK, Kats D, Whetten K, Njamnshi AK, Mbu T, Kefie C, Asanji S, et al. Feasibility, safety, acceptability, and preliminary efficacy of measurement-based care depression treatment for HIV patients in Bamenda, Cameroon. AIDS Behav. 2014;
    1. Adams JL, Almond ML, Ringo EJ, Shangali WH, Sikkema KJ. Feasibility of nurse-led antidepressant medication management of depression in an HIV clinic in Tanzania. Int J Psychiatry Med. 2012;43(2):105–117. doi: 10.2190/PM.43.2.a.
    1. Pence BW, Gaynes BN, Adams JL, Thielman NM, Heine AD, Mugavero MJ, McGuinness T, Raper JL, Willig JH, Shirey KG, et al. The effect of antidepressant treatment on HIV and depression outcomes: results from a randomized trial. AIDS. 2015;29(15):1975–1986. doi: 10.1097/QAD.0000000000000797.
    1. Wagner GJ, Ngo V, Goutam P, Glick P, Musisi S, Akena D. A structured protocol model of depression care versus clinical acumen: a cluster randomized trial of the effects on depression screening, diagnostic evaluation, and treatment uptake in Ugandan HIV clinics. PLoS One. 2016;11(5):e0153132. doi: 10.1371/journal.pone.0153132.
    1. Pierce D. Problem solving therapy - use and effectiveness in general practice. Aust Fam Physician. 2012;41(9):676–679.
    1. Abas M, Bowers T, Manda E, Cooper S, Machando D, Verhey R, Lamech N, Araya R, Chibanda D. Opening up the mind’: problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the friendship bench project in Zimbabwe. Int J Ment Heal Syst. 2016;10(1):39. doi: 10.1186/s13033-016-0071-9.
    1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th (text revision) edition. In. Washington, DC; 2000.
    1. Kroenke K, Spitzer R, Williams J. The PHQ-9: validity of a brief depression severity measure. Gen Intern Med. 2001;16:606–613. doi: 10.1046/j.1525-1497.2001.016009606.x.
    1. Gelaye B, Williams MA, Lemma S, Deyessa N, Bahretibeb Y, Shibre T, Wondimagegn D, Lemenhe A, Fann JR, Vander Stoep A. Validity of the patient health questionnaire-9 for depression screening and diagnosis in East Africa. Psychiatry Res. 2013;210(2):653–661. doi: 10.1016/j.psychres.2013.07.015.
    1. Cholera R, Gaynes B, Pence B, Bassett J, Qangule N, Macphail C, Bernhardt S, Pettifor A, Miller W. Validity of the patient health Questionnaire-9 to screen for depression in a high-HIV burden primary healthcare clinic in Johannesburg, South Africa. J Affect Disord. 2014;167:160–166. doi: 10.1016/j.jad.2014.06.003.
    1. Monahan PO, Shacham E, Reece M, Kroenke K, Ong’or WO, Omollo O, Yebei VN, Ojwang C. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya. J Gen Intern Med. 2009;24(2):189. doi: 10.1007/s11606-008-0846-z.
    1. Rapport F, Clay-Williams R, Churruca K, Shih P, Hogden A, Braithwaite J. The struggle of translating science into action: foundational concepts of implementation science. J Eval Clin Pract. 2018;24(1):117–126. doi: 10.1111/jep.12741.
    1. Ridde V: Need for more and better implementation science in global health. In: BMJ Specialist Journals; 2016.
    1. Udedi M. The prevalence of depression among patients and its detection by primary health care workers at Matawale health Centre (Zomba) Malawi Med J. 2014;26(2):34–37.
    1. Stewart RC, Umar E, Tomenson B, Creed F. A cross-sectional study of antenatal depression and associated factors in Malawi. Arch Womens Ment Health. 2014;17(2):145–154. doi: 10.1007/s00737-013-0387-2.
    1. Pence BW, Gaynes BN, Atashili J, O'Donnell JK, Tayong G, Kats D, Whetten R, Whetten K, Njamnshi AK, Ndumbe PM. Validity of an interviewer-administered patient health questionnaire-9 to screen for depression in HIV-infected patients in Cameroon. J Affect Disord. 2012;

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner