The Role of Depression Screening and Treatment in Achieving the UNAIDS 90–90–90 Goals in Sub-Saharan Africa

AIDS and Behavior (2019) 23:S153–S161 https://doi.org/10.1007/s10461-019-02593-7 ORIGINAL PAPER The Role of Depression Screening and Treatment in Achieving the UNAIDS 90–90–90 Goals in Sub‑Saharan Africa Kazione Kulisewa1 · Melissa A. Stockton2 · Mina C. Hosseinipour3,6 · Bradley N. Gaynes4 · Steve Mphonda3 · Michael M. Udedi5 · Brian W. Pence2 Published online: 17 July 2019 © The Author(s) 2019 Abstract Despite widespread HIV screening and treatment programs across sub-Saharan Africa, many countries are not on course to meet the Joint United Nations Program on HIV/AIDS 90–90–90 targets. As mental health disorders such as depression are prevalent among people living with HIV, investment in understanding and addressing comorbid depression is increasing. This manuscript aims to assess depression and HIV management in sub-Saharan Africa using a 90–90–90 lens through a discussion of: depression and the HIV care continuum; the state of depression screening and treatment; and innovations such as task-shifting strategies for depression management. Due to the lack of mental health infrastructure and human resources, task-shifting approaches that integrate mental health management into existing primary and community health programs are increasingly being piloted and adopted across the region. Greater integration of such mental health care task-shifting into HIV programs will be critical to realizing the 90–90–90 goals and ending the HIV epidemic. Keywords Mental health disorders · Depression · Sub-Saharan Africa · HIV/AIDS · UNAIDS 90–90–90 Introduction Despite widespread HIV screening and improved treatment programs across sub-Saharan Africa (SSA), many countries are not on course to meet the Joint United Nations Program * Kazione Kulisewa 1 Department of Mental Health, College of Medicine, University of Malawi, Private Bag 360, Blantyre, Malawi 2 Epidemiology Department, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 135 Dauer Dr, Chapel Hill, NC 27599, USA 3 Tidziwe Centre, University of North Carolina Project-Malawi, Private Bag A‑104, Lilongwe, Malawi 4 Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, 333 S Columbia St, Chapel Hill, NC 27516, USA 5 NCDs & Mental Health Unit, Ministry of Health, Malawi, Ministry of Health, Capital City, P. O. Box 30377, Lilongwe 3, Malawi 6 Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, 321 S Columbia St, Chapel Hill 27516, North Carolina, USA on HIV/AIDS (UNAIDS) 90–90–90 targets. Mental health problems—particularly depression—remain a prevalent comorbidity in people living with HIV (PLHIV), directly impacting their quality of life and hampering each 90–90–90 goal from diagnosis to enrollment and retention in treatment, and ultimately viral suppression. This suggests HIV treatment programs in SSA will have to embrace innovations that address mental health challenges. This manuscript aims to assess depression and HIV management using a 90–90–90 lens due to the high prevalence of depression [1] and its importance as a public health burden [2, 3]. First, we will provide some background on HIV and mental health care in SSA. Next, we will discuss depression as it relates to the HIV care continuum, with a particular focus on the 90–90–90 targets. We then will provide an overview of the state of depression screening and management in SSA. Finally, we will describe task-shifting strategies for managing depression among PLHIV and highlight an example of one such program that is integrating depression screening and treatment into HIV care initiation in Lilongwe, Malawi. 13 Vol.:(0123456789) S154 Background Burden of HIV in SSA Of the 36.7 million PLHIV globally in 2015 [4], an estimated 25.5 million resided in the sub-Saharan region [4, 5]. This region still accounted for 66% of the 2.1 million new infections and 800,000 of the 1.1 million HIV-related deaths registered that year [4]. As in other countries, up to 40% of HIV-positive individuals were unaware of their HIV status [6], and of those confirmed to be living with HIV, less than half were on antiretroviral treatment (ART) [4]. These figures demonstrate progress in the fight against HIV, especially in light of the reduced mortality rates, averaging a 39% reduction in HIV-related mortality between 2005 and 2013 [5, 7]. However, the high morbidity of the epidemic continues to burden sub-Saharan communities, hampering the economic productivity of some of the world’s least resourced and low-income countries [6]. UNAIDS introduced the 90–90–90 goals in 2013 to help guide efforts to end the HIV epidemic by 2030. These targets aim to ensure 90% of PLHIV know their status, 90% of those diagnosed with HIV receive sustained ART, and 90% of individuals on ART are virally suppressed by 2020 [8]. To achieve these goals, health systems need to adopt innovations to tackle barriers that have hitherto been under-recognized or unaddressed. The role and impact of co-morbid mental health disorders in HIV treatment is one such area that is increasingly being recognized [9]. Mental Health Disorders and HIV Mental health disorders are diverse conditions that present with abnormalities of thought, emotion and behavior, frequently impairing the function of the individual [10]. Mental health disorders and HIV frequently co-exist. Various studies from African countries have estimated that the prevalence of mental health problems in PLHIV range from 19% [11] to about 50% [1]. One aspect of the complex relationship between mental disorders and HIV is that individuals with mental health or substance use disorders are more likely to engage in behaviors that may increase their risk of acquiring HIV and transmitting the virus, and are less likely to engage with healthcare providers [12]. Improvements in HIV care, namely widespread programs which encourage proactive and provider-initiated HIV testing as well as early and immediate initiation of ART, can potentially render HIV a chronic and manageable disease. However, as seen with other chronic medical conditions, mental health disorders are common, with the 13 AIDS and Behavior (2019) 23:S153–S161 lifetime prevalence of any mental health disorder in HIVpositive populations estimated to range from 38 to 75% [12, 13]. While psychiatric conditions can occur at any stage of HIV infection, they tend to be more prevalent with HIV progression and end-stage disease [12, 14]. The considerable overlap in symptomatology between HIV and the somatic symptoms that feature in common mental health disorders complicates the picture, with HIV care providers frequently under-recognizing the potential burden of comorbid mental health disorders in PLHIV [12]. Unrecognized and untreated, mental health disorders have the potential to impact the entire HIV care continuum from HIV prevention strategies, to diagnosis and retention in ART programs. Although (...truncated)