#MHForAll: Mental Health, HIV and TB
Chair:
David Bryden, RESULTS US
Panellists:
Neerja Chowhary, WHO
Ethel Nakimuli-Mpungu, MQ Researcher
Aneeta Pasha, IRD Pakistan
Vongai Munatsi, Africaid Zvandiri - part of Frontline AIDS READY programme
David Bryden:
This is a critical issue when it comes to the success of Global Fund grants, anyone writing a proposal to the Global Fund has got to take these issues into account. If you just look at TB for example, mental health conditions are associated with poor TB outcomes, and depression is strongly associated with loss to follow up, and lack of adherence to TB treatment, yet only 2% of TB programmes around the world are providing access to routine mental health screening. With HIV we have a similar situation, but fortunately people are taking action, and we have some fantastic panellists here who are going to walk us through what practically we can do to address this situation.
Neerja, What are the WHO doing to ensure that mental health is a part of HIV and TB strategies and responses?
Neerja Chowdhary, WHO:
We need to stress the importance of this topic; mental health is vital to address to ensure a successful response to the HIV and TB pandemics. If we are to achieve the SDGs we cannot do this without addressing mental health. The WHO End TB strategy explicitly calls for HIV and TB mental health support to be integrated into the person-centred approach.
Luckily there are lots of cheap and effective mental health interventions that can be easily rolled out alongside or in conjunction with HIV and TB programmes:
The MH GAP guidelines provide evidence based psychological interventions that can be delivered by non specialists to address mental health in programmes in low resource settings. It includes community management, guidelines for psychiatric support alongside physical health conditions and how to support people with severe mental health disorders. People with psychiatric conditions die on average up to 20 years earlier than others, due to a lack of support. In the MH Gap there are guidelines for drug resistant TB and HIV Antiretroviral therapy (ART).
There are three major opportunities ahead of us to push for the inclusion of mental health into physical health services.
UHC (Universal Health Coverage) - provides us with an umbrella under which we can address commodities including the Leave Noone Behind pledge.
WHO MH Comprehensive Action Plan - a plan outlining how mental health can be included in primary care
This week the Global Fund Board is coming together to discuss it’ strategies for the years ahead. This provides us with a unique opportunity to ensure that Mental Health is a part of the global response to HIV and TB.
WHO have worked with UNAIDS over the past year to advise country teams on where, and how mental health can be addressed in the global fund proposals. We are aware that having guidelines is not enough; countries need support to know how to integrate mental health into their HIV and TB programmes. To this end WHO and UNAIDS will be releasing a mental health and HIV implementation guide.
David Bryden, RESULTS US:
What is the READY Movement and how does its work address the specific mental health needs of adolescents and young people living with HIV?
Vongai Munatsi, Africaid Zvandiri:
The Resilient and Empowered Adolescents and Young People (READY) programme is designed for Children, adolescents and young people, aiming to address the mental health challenges which stop adherence to medication, such as undiagnosed depression.
READY is a partnership of organisations and youth leaders that come together to talk about HIV and support adolesc and young people living with HIV. We are working in four Southern African Countries, training a network of peer supporters.
Peer supporters are equipped with counselling skills and taught to screen for common mental health conditions. We also integrate mental health services into healthcare facilities, and facilitate home visits. We record how many have faced mental health challenges or are supported on medication, and provide counselling or refer them for further support. For example, those with psychosis, who need a practitioner to help them will be referred to a specialist.
READY has also been advocating for mental health support for different age groups. You can read an evidence review of this work here.
David Bryden, RESULTS US:
Ethel, can you tell us about your work in Uganda, training health workers in psychotherapy?
Ethel Nakimulu-Mpungu, MQ researcher:
8 years ago MQ developed group support psychotherapy to narrow the treatment gap in particular in rural communities.In a pilot randomised trial we tested intervention and found it to be highly effective against depression. We then teamed up with the Minister of Health to make this therapy accessible to individuals in rural communities by rolling it out across three districts in northern uganda. We worked with local health centres to find health workers who wanted to learn this new skill. They were then invited to five day training and required to participate in practical training - convening psychotherapy sessions. The health workers had to identify 6-8 people with depression and take them through group therapy sessions whilst being supervised. When they passed this they were able to train lay health workers.
Trained lay health workers are able to go into villages to give health talks on depression and give individuals further evaluation and give group support psychotherapy sessions in the villages. In this way we were able to bring the therapy closer to people in their home.
In this randomised trial it was highlight effective against depression, with individuals staying depression free for up to 24 months after treatment. In the long term treating depression
was able to improve adherence and also improve their viral load.
You can see more about Ethel’s work here, and see this article on Effectiveness and cost-effectiveness of group support psychotherapy delivered by trained lay health workers for depression treatment among people with HIV in Uganda: a cluster-randomised trial.
David Bryden, RESULTS US:
Aneeta, as the technical advisor for mental health for the Indus Health Network - recipients to a large Global Fund grant in 2017, how did you ensure mental health was included in Indus’ TB work?
Aneeta Pasha, IRD Pakistan
We initially started using a lay counselling model similar to the previous panellists. In early 2017 what really helped us to integrate mental health was having some pilot data showing the high prevalence of anxiety in new TB patients, as well as the need for psycho-social interventions and holistic care in WHO guidelines. This led to the evidence based intervention that we wanted to pilot within the Global Fund grant. There was an emphasis on drug resistant TB, although available for DS TB patients as well.
The Global Fund stopped funding for this programme, partly because of the lack of clear outcomes in the short time frame, but we continued providing services to patients.
Since then we wanted to generate evidence pointing to impact. We conducted a research study over two years, to integrate mental health into public and private hospital settings in Karachi. Essentially every time a TB patient walked in we made sure they could see a counsellor for 4-6 sessions.
Over the course of 2 years we found that of all the symptomatic patients who completed mental health intervention, 93% completed their TB treatment, compared to 75% for the symptomatic patients who did not complete a mental health intervention. This demonstrates that mental health care does have an impact on TB interventions.
You can read more on Aneeta’s work here, and also this article is related to her work on integrating mental health within primary care.
David Bryden, RESULTS US:
Neerja, you are soon to publish an implementation guide for integrating mental health services into HIV services, what are the main suggestions of this guide, how can countries integrate mental health into their HIV systems?
Neerja Chowdhary, WHO:
It is very interesting to hear these real field examples of attempts at integration. We are now developing this HIV implementation guide with UNAIDS, and our belief is that integration will not only positively impact HIV but also help with global access to mental health services. It serves to support the practical implementation of the evidence based approaches into programmes and is being developed with global experts and field partners.
We know there are many opportunities across the care continuum for mental health integration into HIV and TB programming - across promotion, prevention, recovery, etc. These interventions also need to address children, youths, and families, as well as vulnerable populations.
The guide outlines several principles.
Rights based policies and plans must be present to incorporate these plans into interventions.
Advocacy must shift attitudes and behaviours towards people with these conditions
Training for HIV and TB workers, both in pre-service and ongoing learning, is needed
We must remember that these tasks for healthcare working must be realistic and doable
We need to ensure access to mental health support and psychological treatments
Collaboration needs to occur across government, NGOs, faith groups, and communities
Finally we need shared goals across TB, HIV and mental health and substance use treatment services
David Bryden, RESULTS US:
What roles can young people themselves take to support the mental health of their peers? What are the limits of those roles?
Vongai Munatsi, Africaid Zvandiri:
Mental health services are being delivered by lay health care workers as we know that mostly in Africa and in Zimbabwe we do not have a lot of mental health practitioners. There is 1 psychiatrist to a million people, so it is difficult to get services. This is particularly true within HIV itself.
The role of peer support is great as they are a resource we can tap into to train in mental health interventions that they can pass onto their peers. Right now in Zimbabwe we have trained individuals to screen for anxiety trauma depression and identify common mental health conditions and give support. They have learned the basics of psychological first aid to assist if someone is suicidal or depressed and know when to refer and how to follow up on this. They are also good in terms of advocacy. Many have learnt to take away the stigma that is associated with mental illness. This can help reduce discrimination, which is compounded if someone is HIV positive.
There are limitations however - young people are very susceptible and vulnerable to common mental health condition themselves. So self care is very important. This is an important tool and resource that we need to invest in and support fully. Sometimes people think that peer supporters, because they are role models, must not have a bad day - which is impossible! They are also vulnerable to peer pressure. We need to be able to support them on their off days to enable them to continue their important role.
David Bryden, RESULTS US:
That’s so important. We need to work with young people and involve them but be cognizant of their concerns.
So turning back to Ethel, this programme has the potential to be scaled up to other areas in Uganda, and elsewhere. Have you seen an increased demand for this kind of low resource, scalable intervention? What else do we need to consider when trying to make mental health support more accessible in low resource settings?
Ethel Nakimulu-Mpungu, MQ researcher:
After the results from our trial many groups have been interested in PSS. Local groups are training healthcare workers in health centres in PSS, although unfortunately COVID has interrupted this progress in some cases.
Now we also have researchers who are starting to look at PSS much more - a comparative study in three Kampala health centres is currently being conducted. Education happens best when people visit PHC centres, but in the general population knowledge of common mental health problems is very low. When they are able to identify the individuals with depression, they now have therapy they can offer. The PSS therapy patients have been very responsive and health centres want these programme to continue but this is dependent on funding.
Heads of regional hospitals are now looking for co-funders as they also want their healthcare workers to be trained in PSS.
David Bryden, RESULTS US:
You raised a critical issue of funding, but before we come back to that I just want to get a few brief comments from Aneeta. Can you tell us what were the best mental health interventions that worked alongside the TB programmes? And was it a challenge to make sure that these were included in the proposal to the Global Fund, and has funding been sufficient?
Aneeta Pasha, IRD Pakistan
We found that it is successful when the integration is incorporated within existing TB programmes - for example mental health appointments during the same visit for a patient, so they don’t need to go to a separate place and it’s just another step in the process as part of the regular appointment. So the screening is part of the initial TB visit and in the same facility. The buy-in of the healthcare professionals at the TB facility/clinic was also critical. This reinforces the message of the importance of PSS as they all need to be encouraging the mental health check in. Medical personnel are sometimes seen as authority figures, so having someone say it was important has been crucial to the success of the programme.
We also found it successful that outside of the facilities and in the communities, especially in Pakistan, we’ve set up community advisory groups. These are groups within the community that critically engage with the trial, they are our link to the community to understand the stigmas and perceptions of our work. These also help engage the community and move away from the traditional top-down biomedical model.
David Bryden, RESULTS US:
And what are some of the challenges you faced in ensuring that mental health was included in the proposal to the fund? This is something relatively new and that maybe not all national TB programme managers are familiar with. It’s also, as you said, in some ways a departure from the traditional bio-medical model. So was it all smooth sailing in working with the writers of the actual proposal?
Aneeta Pasha, IRD Pakistan
For us it was important to show the evidence, but the larger challenge was not so much at the time of writing but rather in getting continued support for funding. The interest was in showing immediate outcomes and impact, which sometimes take more time with mental health, and so it was a challenge to convince them that it was something that still has value. Now we are in a place to show that and prove it, but at that time when the Global Fund discontinued the funding that was one of the challenges.
One of the other things was that as part of generating evidence to show impact we also did a time driven activity based costing study, looking at the time it takes to integrate services. This was for advocacy, to show people the impact we were having, as well as the resources required. We hope that very soon we will be able to publish this, and this kind of evidence and data is critical for sustained funding.
David Bryden, RESULTS US:
A lot of questions have been submitted, and there is a lot of interest in published research and documentation of your work. But the first question is what impact has COVID had? And how have you mitigated the challenges that have arisen as a result?
Aneeta Pasha, IRD Pakistan
Pakistan also went into lockdown in April. It was a new thing for everyone and it was a complete shutdown. The biggest issue was that people could no longer access treatment. So we pivoted our mental health programme and had all our trained counsellors and set up a hotline for people to call in and also proactively calling people who had tested positive for COVID. In the Pakistani context there were often 8 or 10 people living in a house and then suddenly having to isolate, so there was uncertainty on how to best do this and how to cope. So we talked them through this and discussed any symptoms etc. Since COVID began they have called 30,000 people, allowing us to continue that mental health support.
David Bryden, RESULTS US:
And another question, how does the model you have developed compare in cost to the traditional approach?
Ethel Nakimulu-Mpungu, MQ researcher:
We were able to assess the cost effectiveness of our intervention, and our analysis shows that the intervention is more cost-effective than just the HIV education model. So because we used lay health workers who were given financial incentives for PSS interventions, despite the cost increase it was still cost effective given the impact it had on the individuals.
David Bryden, RESULTS US:
When it comes to implementation what have you learned is most important for clinician buy-in? What are the issues of attrition?
Ethel Nakimulu-Mpungu, MQ researcher:
It’s really about the health workers - we have to select motivated health workers who want to learn a new skill. These could be midwives, social workers, general nurses. But they have to have the interest and be committed and able to train others. Stakeholders must also allow healthcare workers to take on the role and fund them to keep implementing their work.
David Bryden, RESULTS US:
My last question, how receptive do you think the Global Fund is to these kinds of interventions?
Neerja Chowdhary, WHO:
I believe we have started the conversation, and that is important. This webinar is one step towards working with the GF on this. We know there have been some countries who have included mental health and specific activities that they can do to integrate mental health into their funding proposals, so we have begun to make some progress. We have to just keep reaching out and advocating to show that this is doable.
David Bryden, RESULTS US:
I think you hit it on the head there. The responsibility comes back to us to help the Global Fund adopt these approaches. The Partnership Fora next year is a key opportunity to influence the Fund, let’s do so.
