Abstract
Depression is highly prevalent among people living with HIV in Malawi. Depression can undermine engagement in HIV care and worsen HIV morbidity and mortality. The Ministry of Health integrated a pilot depression management program into HIV care at 2 clinics. This program included a measurement-based care protocol for prescribing antidepressants and an adapted Friendship Bench psychotherapy protocol for providing problem solving. Early evaluations indicated successful integration of the initial stages of training and depression screening, diagnosis, and treatment initiation. This follow-up mixed-method investigation contextualizes our previous findings and shares insights from the implementation experience. We conducted a mixed-methods process evaluation drawing on both patient clinical data and qualitative interviews with patients and clinic staff. We focus on the following implementation outcomes: fidelity, acceptability, and sustainability. Although fidelity to depression screening and treatment initiation was high, fidelity to the follow-up treatment protocol was poor. Antidepressants and problem-solving therapy were acceptable to patients, but clinic staff found delivering treatment challenging given constrained human resources and infrastructure. The program was not sustained after the project. Key identified needs included substantial support to supervise the implementation of the program, continue to build and maintain the capacity of providers, integrate the program into the electronic medical records system, and ensure the availability of Friendship Bench counselors. Although initial steps were successful, sustained integration of this depression treatment program into HIV care in this setting met greater challenges. Implementation science studies that support both implementation and evaluation should recognize the potential for clinical implementers to rely on evaluation staff for clinical support and consider distancing evaluation staff from the actual program implementation. Further research is needed to test enhanced implementation strategies for integrating evidence-based mental health interventions into existing health care systems in a sustainable fashion, particularly in low-resource settings.
Highlights
The burden of depression is high among people living with HIV, in sub-Saharan Africa (SSA).[1]Depression hinders engagement in HIV care and antiretroviral therapy (ART) adherence, which
Clinic staff and leadership did suggest certain resources would be key to supporting the sustainability of the program. These included increasing the number of trained staff, Friendship Bench providers; offering refresher trainings and opportunities for continued learning; providing ongoing supervision; maintaining the stock of antidepressants; and having space for providing screening and counseling. This mixed-methods evaluation of an integrated depression treatment program found that, while early stages of training, depression screening, diagnosis, and treatment initiation were successfully integrated,[17] treatment was not delivered as intended over time, clinic staff had mixed attitudes regarding the acceptability of the program, and sustainability was lacking
The use of mixed-methods approaches is useful for evaluating implementation outcomes,[21] and in this case, the qualitative interviews helped to contextualize and provide nuanced information around the program’s shortcomings. This mixed-methods evaluation of a depression treatment program using antidepressants and psychotherapy in HIV clinics in Malawi found that the early stages of integration and treatment initiation were successful,[17] follow-up care was not delivered as intended, clinic staff had mixed attitudes regarding the acceptability of the program, and the program was not sustained
Summary
The burden of depression is high among people living with HIV, in sub-Saharan Africa (SSA).[1]Depression hinders engagement in HIV care and antiretroviral therapy (ART) adherence, which . The Ministry of Health integrated a pilot depression management program into HIV care at 2 clinics. This program included a measurement-based care protocol for prescribing antidepressants and an adapted Friendship Bench psychotherapy protocol for providing problem solving. Evaluations indicated successful integration of the initial stages of training and depression screening, diagnosis, and treatment initiation. This follow-up mixed-method investigation contextualizes our previous findings and shares insights from the implementation experience. Conclusions: initial steps were successful, sustained integration of this depression treatment program into HIV care in this setting met greater challenges. Further research is needed to test enhanced implementation strategies for integrating evidence-based mental health interventions into existing health care systems in a sustainable fashion, in lowresource settings
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