AIDS Turning the Tide Together “ There is no Health without Mental Health”: Promising models of integration Melissa Sharer AIDSTAR-One

MH and HIV: The Missing Link? Overall PLHIV with positive MH have improved adherence, improved retention, and improved QoL Two directions: – PLHIV have higher rates of depression and other CMD. – Those with MI are more at risk for HIV Three connections: – Reduced adherence – Reduced retention – Higher mortality and morbidity WHO 2008

Mental Health and HIV Timeline In December 2009, AIDSTAR-One produced a technical brief which summarizes the evidence on MH issues of PLHIV and provide clear guidance for programmers in resource-limited countries. Available at:

Framework for Mental Health Services

Vietnam: FHI360 Integration of Mental Health into HIV Care and Support September 2010: Documents the process of integrating stronger mental health services into an existing HIV treatment, care and support program

Protocol: Vietnam Mental Health and Social Support 3. CHBC/PLHIV SG *Screen and refer clients with MH problems to Doctor and or Counselor 4. Follow-up visits *Re-assess for emotional and social problems Provide one-on-one counseling Refer for social support 1.Identification (refer through Doctor, CHBC and PLHIV Support Group) 2. Counselor Complete intake form Assess for depression/anxiety using SRQ20 Develop care plan Provide counseling; referrals for social support Refer to physician if treatment needed 5. Group counseling *Refer clients with mental health and Social problems to group counseling sessions 6. Discharge (When clients are better and no longer need support)

Northern Uganda: Peter C Alderman Foundation Integration of HIV INTO MH services January 2011: MH professionals working in trauma clinics are trained to provide appropriate services for PLHIV living in post-conflict settings

Common themes, challenges, recommendations and lessons learned Starting small Using data to inform practice Struggling to meet the needs of men Quality assurance Country Ownership Referral systems

Zimbabwe 2012: Pushing the Envelope Forward July 2012: Stepped care model where simple interventions are first utilized and more complicated interventions are reserved for clients who have not improved through simple interventions. A client with a positive screen Simple counseling intervention, referral to CBO, health provider for further management More intensive counseling therapy Medication Therapy Intensive psychotherapy, medication therapy and potential hospitalization for stabilization Increasing treatment intensity Clients with Suicidal Ideation and Alcohol and Substance Use emergencies require immediate care

Step 1: Screen

Step 2: Therapeutic Intervention- Evidence Based Reinforced 1) education; 2) therapeutic advice; 3) counseling for behavior change (psycho-education) Motivational Interviewing reinforcing OARS (open ended, affirmations, reflections, summaries) Readiness Ruler (importance and confidence) Counseling tips specific for harmful substance use

Step 3: Refer

Health Facility: Client has a positive SSQ (≥ 8) or CAGE (≥ 1) Community and Traditional Healers: A score of 7 or greater to the sad or worry questions or a “yes” to the alcohol and substance use question. Clinician: Provides routine mental health care to client including counseling and medication where appropriate Psychosocial Services and Support within the community for all clients (inclusive of registered traditional healers) Family Support where appropriate for all clients In-Patient: When a client can no longer be safely managed within the community (a danger to self or others) The CBO should assess for suicidal ideation and acute alcohol withdrawal. If either is present, the client should receive an immediate referral to a health care provider. An SSQ ≥10, suicidal ideation or acute alcohol withdrawal should receive an immediate referral to best qualified health care provider for further care.

“There is no Health without Mental Health” -Dr Sekai Nhiwatiwa, 2012 “Start by doing what's necessary; then do what's possible; and suddenly you are doing the impossible.” -St Francis of Assisi, 12 th century

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