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Over the last two decades, the world has made huge gains in the control of the HIV epidemic. But now, these gains are at risk of stalling.
This is because advances in HIV testing and in improving the lives of people with HIB are not spread evenly across countries and age groups. One group frequently struggling to access these advances is young people.
Older teens and young adults are the most likely to become infected and tend not to go for testing, so they are delayed in getting onto treatment. Of the 1.8 million new HIV infections in 2017, the highest number were in sub-Saharan Africa, with young women accounting for a quarter of all new cases, most of them being infected through the ongoing pattern of transmission from older males.
The theme of this year’s World Mental Health Day was Young People and Mental Health in a Changing World. Young people living with HIV face high levels of stigmatisation, and fear of peer-rejection is at peak in this age group. Therefore, they are at greatest risk of poor outcomes and are less likely to disclose their HIV status or stick to treatment regimens.
Early adulthood is also the peak age for emergence of mental disorders. The risk of acquiring HIV goes up for people living with conditions like depression, anxiety, alcohol misuse and substance use disorders, and for people who have experienced trauma. At the same time, once a person acquires HIV, their risk of developing a mental disorder increases. This adds up to a critical situation: psychiatric care for young people at risk of acquiring, or already living with, HIV must improve.
Another factor adds to the burden. Countries with the highest HIV burdens often have chronic shortages of psychiatrists and psychologists. Poor mental health and poor engagement in HIV testing often go hand-in-hand. So, what can be done?
One major barrier to increasing the number of people undergoing HIV testing is fear: fear of receiving a positive diagnosis, of being judged by peers, of a lack of confidentiality, and of death. Yet life expectancy for someone who tests positive for HIV and sticks to anti-retroviral therapy is close to normal, and an undetectable viral load makes their HIV virtually untransmittable to others. Mental health specialists could advocate for testing programmes that address such fears and increase understanding.
Another barrier is lack of mental health treatment options in many of the countries with the highest HIV burden. Mental disorders, if left untreated, are some of the chief reasons why people living with HIV give up on their antiretroviral therapy, leading to a surge in their viral load, loss of physical health and the risk of infectiousness to others.
Our work in Zimbabwe has shown that global mental health specialists can train and support non-specialist health workers, so they can assess and treat common mental disorders in people living with HIV. Having a cadre of community workers in poor countries could be a game changer in widening access to mental health care.
Through the Friendship Bench in Zimbabwe, we have trained “grandmother health workers” to screen people for depression and for local manifestations of stress such as “thinking too much”. We have found that these wise, kind and committed older women, with supervision, can provide effective talking therapy for common mental disorders for people living with HIV, a therapy they term “Opening Up the Mind”.
Early results indicate that young people are as comfortable as older adults to open and talk to these trained grandmothers. We have also found it feasible to train counsellors working in HIV clinics in Zimbabwe to use more motivational and collaborative approaches with patients who don’t take their prescriptions properly, which has better results than relying on “finger-wagging” approaches or scare tactics.
Global mental health specialists could also urge governments, NGOs and the pharmaceutical industry to roll out modern drug treatments for those with severe mental disorders. This should be combined with routine inquiries about intimate relationships, provision of sexual health care and behavioural interventions for reducing risky sexual behaviour.
Syringe exchange programs are effective in managing HIV transmission for those at risk and should be scaled-up. Pre-Exposure Prophylaxis (PrEP) is an important part of achieving epidemic control. Once it becomes accessible in resource-limited settings, it will be critical that mental health treatment and additional behavioural support are made available, because of the risk of poor adherence to PrEP for someone with a co-existing mental health condition.
UNAIDS has the 90-90-90 goal. By 2020 the aim is for 90% of people living with HIV to know their status, 90% of these to receive antiretroviral therapy and 90% of those receiving antiretroviral therapy to be virally suppressed. These goals can only be achieved if mental health specialists are contributing to sustainable, culturally appropriate healthcare programmes.
Melanie Abas is a reader of global mental health at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London in the United Kingdom.