Atalay Alem , MD, PhD Department of Psychiatry, Addis Ababa University, Ethiopia

1. Exploring Alcohol Use, Gender-based Violence and HIV/AIDS:Can Community Mental Health Care Address Alcohol, Gender-based Violence and HIV/AIDS? AtalayAlem, MD, PhD Department of Psychiatry, Addis Ababa University, Ethiopia XIX International AIDS Conference, Washington DC, USA July 26, 2012

2. Magnitude of mental health problems • WHO estimates that, there are 450 million people affected by mental and neurological disorders worldwide • more than 150 million people suffer from depression. • 125 million people are affected by alcohol-use disorders. • 40 million people suffer from epilepsy

3. Magnitude of mental health problems • 24 million have Alzheimer’s disease and other dementias. • Every year, nearly one million people take their own lives. • WHO further estimates that mental, neurological, and substance use disorders account for 14% of the global burden of disease.

4. Mental health problems and HIV infection • The association between alcohol use/abuse and high risk sexual behavior for HIV has long been well established • Mental health problems are also shown to increase risk behavior for HIV

5. Mental health problems and HIV infection • A recent Ugandan study in a rural district showed association between risky sexual behavior and • Depression • Intimate partner violence • Alcohol abuse/use • Other socio-demographic variables Kinyanda, et al. AIDS; 2012

6. Substance use & HIV Risk Behavior • A nationally representative sample of 20,434 youth were asked about their use of alcohol and khat, and their sexual behaviour. • Daily khat users were twice more likely to have unprotected sex • Daily use of alcohol was also associated with unprotected sex.

7. Unprotected sex and problem drinking among female sex workers in Ethiopia A random sample of 2,487 female sex workers (FSWs) from 7 urban centres in Ethiopia were interviewed regarding their sexual behaviour and substance use.

8. Problem Drinking and Unprotected Sex in Female Sex Workers Main Findings • About 12% of FSWs reported having unprotected sex in the preceding 12 months. • Both occasional alcohol intakeand problem drinking increased the risk of unprotected sex. • Women who drank alcohol daily were at increased risk of sexually transmitted infections.

9. Mental health problems and HIV infection • Mental ill health and alcohol not only increase the risk of infection, but also affect outcome • A systematic review to see mental disorders and outcome of HIV/AIDS in low and middle income countries was done recently • The review found out that there is clear evidence that adverse mental health and alcohol consumption are associated with reduced adherence. Unpublished review, 2012

10. Gender based violence and HIV Domestic violence & mental health The 1996 amended definition for violence against women “ any act of gender-based violence that results in or is likely to result in physical, sexual or psychological harm or suffering”

11. Domestic violence & mental health • Over a third of women in the world get abused by their husbands • Magnitude of mood, anxiety & somatoform disorders are higher • Over 3,000 women were interviewed for domestic violence and Depression in Ethiopia

12. Domestic violence & mental health • 59% reported lifetime sexual violence • 44% in the preceding 12 months • 49% reported lifetime physical violence • 29% in the preceding 12 months

13. Domestic violence, mental health & HIV • Prevalence of depression • 7.3% in those who had been abused • 3.3% in the non abused group. Deyessa et al; 2009 • It is known that gender-based violence has a 4 fold increased risk for HIV infection

14. Mental Health Problems and Service Gap Treatment Gap • > 66% of people with mental illness receive no treatment • under-treatment occurs in all countries: • 67% in USA, • 74% in Europe and up to • 98% in Nigeria receive no treatment • by comparison only 8% of people with type 2 diabetes mellitus in Europe receive no care • About 4 out of 5 cases of MNS, and substance use conditions do not receive treatment in LMICs

15. Treatment Gap in Ethiopia

16. Mental Health Problems and Service Gap • It is not feasible for LMICs to train enough specialists needed for community mental health service • Training non specialist frontline workers is the only alternative there is to bring mental health services close to the community in these settings • Primary HIV/AIDS care is being provided by these people after a short term training

17. Mental Health Problems and Service Gap • WHO recently launched the mental health Gap Action Programme (mhGAP) for LMICs. • Objective of mhGAP is scaling up care for priority conditions • mhGAPIntervention Guide (mhGAP-IG) has been developed

18. Mental Health Problems and Service Gap • The mhGAP-IG is brief so as to facilitate interventions by busy non-specialists in low- and middle-income countries. • The mhGAP-IG includes guidance on evidence-based interventions to identify and manage a number of priority conditions.

19. Mental Health Problems and Service Gap The priority conditions included in mhGAP-IG include Dementia Alcohol use disorders Drug use disorders Self-harm / suicide and Other significant emotional or medically unexplained complaints. • Depression • Psychosis • Bipolar disorders • Epilepsy • Developmental and behavioral disorders

20. Can Community Mental Health Care Address alcohol, Gender-based Violence and HIV? Community Mental Health Care High-income country context • In the community/ outside health institutions • Specialist case teams • Diverse professionals • Case workers • Home visits, personal and social needs addressed Low-income country context (African) • Institution based (secondary care level) • Lower level health workers • Medical model interventions

21. Can Community Mental Health Care …? • 5 LMICs are now launching an intervention study to produce evidence for mental health care at primary care settings • This project could be a good model for the subject in question for this presentation • The project is called PRIME • PRIME is an acronym for “PRogram for Improving Mental health CarE”

22. Purpose The purpose of PRIME is to generate world class research on the implementationand scaling up of treatment programmes for priority mental disordersin primary and maternal health care contexts in low resource settings. Photo: Mental Health & Poverty Project (MHaPP) Nepal India Ethiopia Uganda South Africa

23. Can Community Mental Health Care …? • PRIME is a consortium of research institutions and Ministries of Health in five countries in Asia and Africa and, partners in the UK and the WHO. • South Africa • Ethiopia • Uganda • India • Nepal • PRIME is supported by the DfID (UK) and is a six year program which was launched in May 2011.

24. Principles of PRIME • Starting point: robust evidence on cost-effective interventions – not “what” but “how” • Partnership • Focus on priority conditions: • depression • alcohol use disorders • schizophrenia (psychosis) • epilepsy (in Ethiopia and Uganda) • Use building blocks of a mental health plan at 3 levels: • Health care organization • Health facility • Community • Focus on key disadvantaged groups: the poor, women and people living with mental illness

25. Functions at the 3 levels

26. Can Community Mental Health Care …? • Alcohol related problems are among priority conditions for PRIME • HIV care is already being provided in these settings • What remains to be included in the package to answer the question “can community mental health care address alcohol, gender-based violence and HIV/AIDS?” is gender based violence.

27. Can Community Mental Health Care …? • Gender-based violence can be included in the package. • However, what care providers at this level can do to minimize the risk and to help the victims needs to be carefully studied. • Because it is not only a health care issue, but it is a human right issue as well • It requires a concerted effort from all sectors of social services to properly deal with the problem

28. Can Community Mental Health Care …? • In LMICs we cannot talk of community mental health care as a separate program • We can only think of it as an integral part of general health care program

29. Can Community Mental Health Care …? • Involving health care organizations, health facilities and the community about the packages of mental health care at primary care level is vital. • If these stakeholders are all onboard it is possible that community mental health care can address alcohol, gender based violence and HIV in LMICs

30. Thank you