Kimberly Green Regional Technical Advisor FHI Viet Nam/APRO Mental Health, Drug Use, Gender, and HIV: Baseline Results from a Longitudinal Palliative Care Intervention Study in Viet Nam Kimberly Green Regional Technical Advisor FHI Viet Nam/APRO K. Green1,2, T. Tran3, H. Tran Vu1, T. Nguyen Nguyen4, H. Nguyen Duc5, P. Vu Ngoc1, T.H. Nguyen Thi1 1 FHI Vietnam, Hanoi, Viet Nam 2 LSHTM, London, United Kingdom, 3 RTCCD, Hanoi, Viet Nam, 4 Life Centre, Hanoi, Viet Nam, 5 Van Don District Hospital, Van Don, Viet Nam

Background Depression in HIV is often under-diagnosed and under-treated. Associated with reduced adherence and retention in care, symptom severity, morbidity and decreased CD4 count (Gordillo et al 1999; Holmes et al 2007; Lampe et al 2010; Lesserman et al 2002, Lima 2007; Sher et al 2008) High rates of mental health problems have been reported among women and injection drug using populations with HIV (Ammassari et al 2007; Carrieri et al 2007, Tran et al 2010, Vogl et al 1999) Findings from FHI cohort study among people living with HIV (PLHIV) on antiretroviral therapy (ART) in Ho Chi Minh City found reduced levels of quality of life over time in emotional and social domains (Tran et al 2010) Palliative care, including mental health care, had not been well integrated into HIV out-patient clinics in Viet Nam

Study design In 2009. FHI initiated an intervention study to evaluate integration of palliative care and mental health services into OI/ART clinical services Design: Two-arm non-randomized controlled trial comparing integrated palliative care to standard HIV out-patient care services (OI, ART, etc); and an embedded qualitative study Location: Quang Ninh province, Northern Viet Nam Baseline sample size: 822 (32% female) Data collection: Four rounds of data collection - two pre-tests and two post-tests Intervention: Structured routine palliative care assessment; clinical mentoring; mental health screening and care

Demographic characteristics

Baseline findings – Depression and anxiety

Findings by sex

Baseline findings – Multivariate regression analysis Depression: Women at greater risk of symptoms of depression than men (P=0.002) Among male PLHIV, those with a history of drug use in the past six months are at significant risk of symptoms of depression (P<0.0001) Depression symptoms also associated with stigma and discrimination (P<0.0001), poor health function (P<0.0001), perception that health affects one’s ability to work (P<0.0001), and ART side-effects in the past month (P=0.0004) Anxiety: Anxiety was strongly associated with ART side-effects in the past month (P<0.0001), perception that health affects one’s ability to work (P<0.0001), stigma and discrimination (P=0.005) and female sex (P=0.01)

Mental health care needs of injection drug users “…What they [drug users] need most is mental care because drug users often sink into drugs. Drug users are often looked down with contempt. Their families abandoned them. Their friends and people in the society also keep away from them. This leads drug users to sink into using drugs, so they cannot give up. If they receive mental care and spiritual support from their families and the society, I think they are able to give up using drugs. I think what drug users need first is mental healthcare...” (PLHIV_Male_Site A_0010

Knowledge contribution and recommendations Presence of depression symptoms among PLHIV in this study is high compared to general population Structured mental health counseling needs to be integrated into HIV ART and other HIV care services Particular attention needs to be provided to the mental health concerns of those with a history of recent injection drug use and women Improving access to opioid substitution therapy and employment opportunities among IDU is critical for overall wellbeing Screening and treatment of pain and other symptoms and side-effects are essential for improved mental health

Acknowledgements Van Don and Cam Pha district hospitals Clinic clients and families USAID Viet Nam Nguyen Thi Minh Ngoc, Xerxes Sidhwa, Elisa Margolis US-CDC Viet Nam Ho Van Anh, Jodi Charles, Nick Medland Family Health International Steve Mills, Vu Ngoc Phinh, Nguyen Thi Thanh Ha, Nguyen Thanh Hien, Rachel Burdon London School of Hygiene and Topical Medicine Arnab Acharya, Emily Webb, Cathy Zimmerman, Donna Lamping