1. Dixon Chibanda

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 Lay health workers: involved in routine HIV/AIDS care at community level PMTCT: mothers attending 6 weeks postnatal clinic visit 1.Validating tool (EPDS) 2. Training LHW in PST 3.Define stepped care and red flag referral 4..Define outcome measures Local clinics (The Friendship Bench): patients utilizing primary care services 1.Tools ( SSQ-14/ HAQol MSC) 2. Train LHW in PST 3.Define steps /red flags 4. Define outcome measures

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 1) lay health workers Refer red flag cases to 2. 2) Senior counselor/nursing staff local clinic manage or refer severe cases to 3. 3)Psychologist/psychiatrist refer to tertiary facility. Provide weekly supervision to 2 and refer back stable cases to 1.

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