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Using task shifting to integrate mental health services in HIV/AIDS care in Zimbabwe

Dixon Chibanda. Using task shifting to integrate mental health services in HIV/AIDS care in Zimbabwe. Background.

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Using task shifting to integrate mental health services in HIV/AIDS care in Zimbabwe

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  1. Dixon Chibanda Using task shifting to integrate mental health services in HIV/AIDS care in Zimbabwe

  2. Background • In sub-Saharan Africa the result of poor adherence to HAART includes poor treatment outcomes and the emergence of virus resistant to first line treatment regimens. (Bangsberg 2008). • In sub-Saharan Africa depression is associated with poor adherence to ART . (Nakimuli-Mpungu 2011)

  3. Background • Depression, which is part of a wider group of conditions referred to as common mental disorders(CMD) marked by symptoms of depression, anxiety, and somatization increase the risk of HIV disease progression and mortality (Antelman 2007) • Non-pharmacological interventions for depressive disorders have shown promising results in developing countries. (Bolton 2003; Araya 2003; Ali 2003; Rahman 2008;Patel 2011; Petersen 2012)

  4. Background: The challenges • High migration rate of health professionals from poor to rich countries. (Dovlo 2005) • In Zimbabwe it is estimated that in the past 15 years over 50% of health professionals have migrated to South Africa, UK, Australia, and USA.

  5. Rationale for task Shifting • In the absence of health professionals we have had to resort to task-shifting. • ….the delegation of medical and health service responsibilities from higher to lower cadres of health staff, sometimes non-professionals. (Zachariah 2009)

  6. Rationale for task shifting • There is evidence supporting the use and efficacy of using lay health workers in primary and community health care. (lewin 2005) • Task shifting is now widespread in HIV/AIDS care in sub-Saharan Africa. (Zachariah 2009) • ……but with poorly defined mental health packages under the term psychosocial support/ counselling.

  7. Lay health workers in Zimbabwe • There are over 5000 lay health workers involved in HIV/AIDS care in Zimbabwe. (Zimbabwe Aids Network-ZAN). • Most of them (85%) acknowledge the need to address depression (kufungisisa) among PLWH but lack the knowledge. (ZAN)

  8. Integrating Mental health in HIV/AIDS care

  9. Mental health in PMTCT program • Postnatal psychological morbidity is high in Zimbabwe. (Nhiwatiwa 1998; Stranix -Chibanda 2005) • In 2009 PND among women attending PMTCT was 30% (Chibanda 2009) • We validated the Edinburgh Postnatal Depression Scale (EPDS). (Chibanda 2009) • Trained HIV + peer counselors on how to administer EPDS & provide group problem solving therapy . (Chibanda 2011)

  10. PMTCT • Group problem solving therapy was significantly better (p=0.009) than usual care (medication) after 6 weeks. ( Chibanda in press JIAPAC) • Lay health workers are able to screen treat and refer mothers with PND within the PMTCT program . (Stranix-Chibanda 2005; Shetty 2008; Chibanda 2010 )

  11. Primary care mental health • Prevalence of CMD in PHC clinics 24%-30% (Patel 1997; Abas 2000; Chibanda 2011) • The City Health Department in Harare employs ~ 800 lay health workers who are involved in the provision of HIV/AIDS care at community level. • We have successfully trained lay health workers involved in HIV/AIDS care to screen for CMD and provide Problem Solving Therapy (Mynors-Wallis 2001) for depression in Mbare. (Chibanda 2011). Recently added Behavioral Activation – another simple evidenced based intervention for depression - to the skill base of lay workers (Abas, Chibanda, Wingrove, in progress)

  12. The friendship bench

  13. The Friendship bench • Over 4000 people have utilized the friendship bench since its’ inception in 2006, most of these being PLWH. • Using lay health workers who are already involved in routine HIV/AIDS care to provide mental health care appears to be less stigmatizing than seeing a psychiatrist or clinical psychologist. (Chibanda 2011)

  14. Pyramid for mental health integration in HIV/AIDS care

  15. Why it seems to be working • High literacy rate in Zimbabwe (90%) (UNDP 2010) • Existing tools; SSQ-14; SSQ-8 (Patel 1994) Multiple symptoms card with 7-step intervention (Abas 1994) HAqoL(Taylor 2008) EPDS(Chibanda 2009) • A referral system that is accepted by stakeholders. • By end of 2012 will begin a cluster randomized controlled trial of this brief psychological intervention delivered by LHW

  16. Recommendations for integrating mental health in HIV/AIDS care • Guidelines for recognition and care (MhGap) • Development of standardized protocols, including simplified guidelines. (Zachariah 2009; WHO 2007) • Mental health interventions must be implemented into existing programs. ( Collins 2006) • Need to explore how to bring on board traditional healers (Taylor 2008) • Mental health professionals should assume the role of public health consultants (Patel 2000)

  17. Acknowledgement • City Health Department Harare, Dr Chonzi, Dr Mungofa • University of Zimbabwe, Department of psychiatry • University of Zimbabwe Dept comm med • Wake forest University, (Dr Avi Shetty) • Institute of Psychiatry, London Dr. Melanie Abas

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