Abstract
This Background: In South Africa the rising comorbidity of mental disorders with other non-communicable and communicable diseases, particularly in people living with HIV/AIDS (PLWHA), has helped raise the public health priority of mental ill-health. Depression, in particular, compromises anti-retroviral treatment (ART) adherence and virological suppression, thus threatening the effectiveness of South Africa’s ART programme. Given that evidence-based treatment for depression comprises medication and/ or Western-derived psychotherapies, responding to the current interest in expanding mental health services for PLWHA demands an understanding of how best to provide culturally competent care within existing resource constraints. Aim: To explore the context and local understandings of depression in women living with HIV to inform the development of contextually appropriate mental health services that could be delivered within existing resource constraints inSouth Africa. Method: Semi-structured qualitative interviews were held with 35 women living with HIV in South Africa who met the diagnostic criteria for a major depressive disorder. Results: Being HIV-positive per se was not reported to be a major cause of depression. Instead, a number of social factors were reported. These included stigma and discrimination, poverty, and stressful life events. Symptoms of depression, especially social withdrawal, negative ruminating thoughts and excessive worry suggestive of comorbid anxiety, functioned to exacerbate and trap women in a negative depressive cycle. Social support emerged as a dominant coping strategy. Group-based interventions, which afford greater opportunities for improved social support, were mooted as the most appropriate intervention by the majority of participants. Individual counselling provided through a home visitation programme was suggested for those who were too ill or too poor to attend clinics. Task sharing was also endorsed. Conclusion: The need for multi-sector engagement in mental health promotion to address factors that trigger, maintain and exacerbate depression at a community level in PL-WHA is highlighted. The triggers, symptoms and local coping strategies employed by afflicted women in this study suggest a resonance with Western derived evidence-based psychological therapies. In relation to delivery channels, there was support for the provision of group interventions or home-based individual counselling using a task sharing model.
Highlights
The call by the global mental health movement to increase access to mental health services has been spurred by the rising burden of mental, neurological, and substance use (MNS) disorders, which account for 13% of the global burden of disease [1] and the large treatment gap for these disorders
Lack of social support Lack of social support, not being able to share their problems with family, and partners who refused to let them talk about their problems, ignored them or reprimanded them when they tried to talk to them about their problems, emerged as a key factor which contributed to depressive symptoms in almost half the respondents from both provinces (17) (9 in KZN and 8 from NWP):
Our data points to three factors that lead to depression in women who live with HIV, namely, stigma and discrimination; the stressors associated with living in poor socio-economic conditions; and stressful life events, rejection/abuse/abandonment by partners, other family conflicts, multiple loss and other traumatic events
Summary
The call by the global mental health movement to increase access to mental health services has been spurred by the rising burden of mental, neurological, and substance use (MNS) disorders, which account for 13% of the global burden of disease [1] and the large treatment gap for these disorders This gap is high (up to 90%) in low and middle income countries (LMIC) [2]. Common mental disorders (CMDs) co-morbid with HIV/AIDS are of concern to the South African Department of Health as they threaten to undermine the success of the country’s antiretroviral therapy (ART) programme, the largest in the world [5] This is because: 1) CMDs increase risk for poor ante-retroviral treatment (ART) adherence. In SA a recent study confirms this association [7]; 2) Depression and stressful life events are independently associated with accelerated disease course, with psychosocial factors linked to immune suppression [8]
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