Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program

Udedi et al. BMC Health Services Research (2018) 18:593 https://doi.org/10.1186/s12913-018-3388-z RESEARCH ARTICLE Open Access Integrating depression management into HIV primary care in central Malawi: the implementation of a pilot capacity building program Michael Udedi1, Melissa A. Stockton2* , Kazione Kulisewa3, Mina C. Hosseinipour4,5, Bradley N. Gaynes5, Steven M. Mphonda4, Beatrice Matanje Mwagomba6, Alick C. Mazenga7 and Brian W. Pence2 Abstract Background: In Malawi, early retention in HIV care remains challenging. Depression is strongly associated with reduced anti-retroviral therapy (ART) adherence and viral suppression. Appropriate depression care for people initiating ART is likely to be supportive of early and continued engagement in the HIV care continuum. This paper aims to provide an overview of a task-shifting program that integrates depression screening and treatment into HIV care and the strategy used to evaluate this program, describes the implementation process, and discusses key challenges and lessons learned in the first phase of program implementation. Methods: We are implementing a program integrating depression screening and treatment into HIV care initiation at two clinics in Lilongwe District, Malawi. The program’s effect on patients’ depression and HIV outcomes will be evaluated using a multiple baseline pre-post study. In this manuscript, we draw from our experiences as program implementers and some of the quantitative data to describe the process of implementation and key lessons learned. Results: We successfully implemented the screening phase of this program at both clinics; 88.3 and 93.2% of newly diagnosed patients have been screened for depression at each clinic respectively. 25% of enrolled patients reported symptoms of mild-to-severe depression and only 6% reported symptoms of moderate-to-severe depression. Key lessons learned from the process show the importance of utilizing existing processes and infrastructure and focusing on iterative and collaborative learning. We continued to face challenges around establishing a sense of program ownership among providers, developing capacity to diagnose and manage depression, and ensuring the availability of appropriate medication. Our efforts to address these challenges provide insight into the technical and managerial support needed to prepare for, roll out, and sustain integrated models of mental health and HIV care. Conclusions: This activity demonstrates how a depression screening program can successfully be integrated into HIV care within the public health system in Malawi. While this program focuses on integrating depression management into HIV care, most of the lessons learned could apply to integration of mental health into any non-psychiatric specialist setting. Trial registration: ClinicalTrials.gov ID [NCT03555669]. Retrospectively registered on 13 June 2018. Keywords: HIV/AIDS, Mental health, Depression, Sub-Saharan Africa, Malawi, Integration, Service delivery, Implementation science * Correspondence: 2 Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Udedi et al. BMC Health Services Research (2018) 18:593 Background In Malawi a growing body of research is beginning to document the scope of mental health challenges in the general Malawian population. In Malawian primary care settings, 28.8% of all patients (regardless of human immunodeficiency virus (HIV) status) have a common mental disorder [1]; the most common condition appears to be depression. Prevalence estimates of depression among populations living with HIV vary: 19% among adolescents attending HIV clinics [2]; 16% among newly initiating ART adults; and 9% among adults on anti-retroviral therapy (ART) for at least 6 months [3]. However, the lack of national data documenting the magnitude of mental health problems has historically hampered efforts to secure and allocate resources for mental health services. Mental health care infrastructure and human resources in Malawi are limited; there are only four mental health facilities in the country (two public and two private), − only three of which are currently operational – all located in urban centers. Mental health care is treated as a specialized service in Malawi and is primarily offered from these aforementioned facilities. In response to the public health burden of mental health disorders in Malawi, Malawi’s Health Sector Strategic Plan (HSSP 2011–2016) formally recognized the need to address non-communicable diseases (NCDs) in Malawi [4] and established the NCDs and Mental Health Unit of the Ministry of Health (MOH) in the 2011–12 financial year. Further, the 2017–2022 Malawi Health Sector Strategic Plan prioritizes treatment for mental health, including depression treatment, under their Essential Health Package [5, 6]. The NCDs and Mental Health Unit of the MOH developed action plans to 1) integrate mental health services into other general health services; 2) improve the capacity of general health care workers through training to diagnose and manage mental health conditions at different levels of care; and 3) raise awareness of mental health disorders and treatment among the general population through community health workers, teachers, religious leaders, peer educators and the media [7]. As a result of these efforts, a pilot program aimed at building the mental health capacity of community health workers, encouraging community-level mental health promotion and detection, and integrating these community health worker activities into the primary care setting was successfully implemented in Zomba, Malawi [8–10]. However, further efforts are needed to effectively realize the MOH’s mental health goals. Simultaneously, early retention in HIV care is a major obstacle to achieving the Joint United Nations Programme on HIV/AIDS (UNAIDS) 90–90-90 goals [11–13]. The first year of ART is a particularly vulnerable period: nearly a quarter of people initiating ART are lost to care within the first 12 months [11–13]. Among people initiating Page 2 of 12 ART, those with comorbid depression are a large and especially vulnerable population. Depression affects 18 to 30% of patients receiving HIV care in (...truncated)