USAID Jamii Tekelezi is a CHAK-led program that supports HIV services delivery through a structured partnership with the four county governments of Embu, Tharaka-Nithi, Meru and Nyandarua. Implementation of the program, which is funded by USAID, is anchored on the key technical areas of Prevention of HIV, Care and Treatment, Care for Orphans, and Vulnerable Children (OVC) and Health Systems Strengthening.
As efforts to end the AIDS epidemic intensify, communities of people living with, at risk of, or affected by HIV, clinicians, advocates and researchers are increasingly calling for support in mental health and well-being in HIV prevention, treatment and care.
USAID Jamii Tekelezi program has sustained accelerated implementation of Differentiated Service Delivery (DSD) models to drive continuation of treatment (CoT) and ease the health care burden associated with provision of HIV treatment services. Mental health and psychosocial assessment is done regularly in the program to determine evolving barriers to treatment and address client-centered needs. This requires a holistic approach to person-centered HIV services that ensure HIV prevention, treatment and care to address the needs of people with mental, neurological or substance use conditions.
Approaches: The USAID Jamii Tekelezi context
The call for patient level data has seen the program dig deeper into addressing client specific needs. As at semi annual progress review, the program reported 14 clients with mental health illness drawn from various supported facilities in the four implementation counties. Of the 14 cases, 12 of them were females (85 per cent) and 2 were males (15 per cent). The Median age was 48 years with the youngest being 39 and the oldest 62.
The program adopted the PHQ-9 tool to screen for depression and GAD-7 for anxiety. PHQ-9 is an acronym for Public Health Questionnaire, a multipurpose tool for screening, diagnosing, monitoring, and measuring the severity of depression, while the GAD-7 is a generalized anxiety disorder assessment tool. The program’s interventions are tailored to address both mental health disorders and continuity in treatment. Some of the interventions have proven to improve virological suppression, ensuring close attention to coordination and harmonization of service location, service providers, and schedules for clinical appointments, medication dispensing, and laboratory testing.
Among the interventions are: intensified case management, including referral for management of mental health cases, differentiated care interventions, where patients receive a different “dose” or type of intervention, depending on their mental health care needs. Clients are also issued with referral forms for specialized care e.g. in low volume facilities where the mental health aspect is not integrated. Clients with other comorbidities, such as alcohol use disorders, mental health issues, substance abuse, unstable psychosocial contexts such as Intimate Partner Violence (IPV) or facing economic constraints such as lack of income, traveling long distances to health facility/transportation barriers, etc. are prone to suffer from mental health illnesses. The program has tailored various strategies to improve treatment growth/continuity of treatment. These strategies are:
- Health care worker’s mental wellness promotion
- Mental health packaging and materials development
- Mental health service delivery (Identification, first aid, medical management and crisis interventions)
- Community-based mental health programs
- Digital mental health interventions
Mental health integration with other services for Persons Living with HIV
The program continues to implement the following activities in a bid to integrate mental health in the package of care:
- Mental health screening integration into HIV prevention, testing, and/or linkage to ART, including drug and alcohol treatment settings
- Campaigns to increase mental health and HIV knowledge and awareness implemented to address stigma and discrimination
- Support county-specific plans for integrating mental health and/or psychosocial services into routine HIV prevention, care, and treatment services
- Implementing interventions that address mental health disorders and difficulty effectively using biomedical HIV prevention, such as daily oral PrEP among people with mental health or substance abuse disorders
- Integrating evidence-based components to promote engagement and help prevent any deleterious impacts of mental health disorders
Access to quality health services for all populations
To ensure access to quality health care for all populations, HCWs must accelerate the call for inclusion of subpopulations that present a special challenge, including:
- Adolescents and youth: Adolescent and youth-friendly HIV testing and treatment services should include mental health and substance misuse support to help improve linkage among adolescents and youth and referrals to appropriate services.
- Pregnant and breastfeeding women: Support for disclosure and screening for depression may be helpful, and the perinatal period may be an important window for screening for mental health and psycho-social issues among WLHIV.
- Older adults: Emotional support will be provided through informal networks (families) and mental health professionals. Simple facts and precise information are key to improved mental health.
- PLHIV with comorbidities: Integrating mental health screening and care into all HIV and comorbidity screening and treatment settings will strengthen access to mental health care and improve HIV and comorbidity care and treatment outcomes.
- Key population and other vulnerable populations: Peer networks can help facilitate care modalities to improve mental health outcomes in some settings.
- GBV survivors: Providers can deliver psychological first aid and first-line support (LIVES), including safety planning and referral for psychosocial support and mental health services. Social networks are also an important source of support for survivors.
The integration of screening and management of depression in the standard of care of PLHIV is crucial. The program hopes that the following strategies and interventions can be scaled up for adoption:
People-centered services and care
Mental health services must adopt the perspectives of individuals, families, and communities. They must see them as participants and beneficiaries of health services and support that respond to and prioritize their needs and respect their will and preferences in humane, noncoercive, and holistic ways. Engaging individuals who have survived mental health in developing interventions, communication, and education materials are recommended.
Supporting relevant mental health services, psychosocial services, and/or substance misuse services, either in the HIV prevention, testing, care and treatment settings as part of an integrated package of services at the facility and community level or, at a minimum, through a referral for these services provided by a different program. We may consider conducting a landscape analysis of available mental health and/or substance misuse services to understand available resources, the feasibility of referrals, and impressions of service quality. Put in place to facilitate meaningful partnership and barrier mitigation to the referral/linkage process. The referral/linkage process will also request client experience feedback.
Engagement with other players for referrals, including community support groups, religious bodies, and other organizations within the areas of implementation.
Monitoring and evaluation
Monitoring programs to assess the impact of interventions on HIV-related outcomes using standardized methodology and using validated tools to assess mental health and psychosocial status, with consideration for additional scales to measure resilience among people living with HIV and mental health and/or substance misuse disorders.
Technical Writers: Arthur W. Julius O.