# data[].attributes.headline
How does HIV impact womens helath ( Tier 2, Organization, No author stated, goal is to reduce HIV spread)

# data[].attributes.subject
How does HIV impact womens helath ( Tier 2, Organization, No author stated, goal is to reduce HIV spread)

# data[].attributes.body
Pregnant women can pass HIV to babies

Hot Flashes and CD4 Count may drop

Heart attack common

# data[].attributes.attachment_link.readable_text
How Does HIV Affect Women Differently?

HIV may cause some health problems that are unique to women, such as:

Gynecological health issues

Increased risk of cervical cancer

Increased risk of heart disease

HIV medicine side effects and drug interactions

Aging-related issues

Pregnancy and birth control also require careful management with a health care provider.

The good news is that women with HIV who take HIV medicine (called antiretroviral therapy or ART) exactly as prescribed and get and keep an undetectable viral load can live long and healthy lives and have will not transmit HIV to their HIV-negative partners through sex. An undetectable viral load is a level of HIV in your blood so low that a standard lab test can't detect it. Learn more about the health and prevention benefits of viral suppression and having an undetectable viral load.

Gynecological Health Issues and HIV

Gynecological problems are common among women with HIV. Some of the issues women may experience are:

Problems related to sexually transmitted diseases (STDs)-STD screening and treatment are important for all women. However, they are especially important for women with HIV because some STDs, like genital herpes, pelvic inflammatory disease (PID), and chancroid, can happen more often and be more severe and/or harder to treat. Also, having HIV and other STDs may increase the risk of HIV transmission to sexual partners.

Vaginal yeast infections-In women with HIV, vaginal yeast infections can occur more frequently and be harder to treat. Recurring vaginal yeast infections (those that happen at least four times a year) can happen more often in women with advanced HIV or AIDS.

Bacterial vaginosis (BV)-BV is a condition caused by changes in the amount of certain types of bacteria found in the vagina. BV is more common in women with HIV and may be harder to treat.

Menstrual cycle problems-Women with HIV may experience missed periods, lighter or heavier bleeding, or more severe premenstrual syndrome.

Treatment is available for these health conditions. Talk to your health care team about treatment options that are right for you.

Cervical Cancer and HIV

Women with HIV have a higher risk of cervical cancer. It is important that they be screened regularly for this disease.

Cervical cancer starts in the cervix, the lower, narrow part of the uterus (the womb). It is an AIDS-defining cancer. That means that a diagnosis of cervical cancer marks the point at which a person's HIV infection has progressed to AIDS.

Most cases of cervical cancer are caused by the human papillomavirus (HPV). There are many different types of HPV, with some types that cause cervical cancer and other types that do not.

The types of HPV that cause cervical cancer are more common in women with HIV. Cervical cancer is largely preventable through regular Pap tests and HPV vaccination. For this reason, women with HIV need to get regular Pap tests to screen for changing cervical cells before they turn into cancer. Talk to your health care provider about the Pap test schedule that is right for you.

The HPV vaccine is recommended for women (and men) with HIV through age 26 if they have not already been vaccinated. Some adults ages 27-45 who have not already been vaccinated might choose to get the HPV vaccine after speaking with their doctor about their risk for new HPV infections and possible benefits of vaccination.

HIV Medicine Side Effects and Drug Interactions

HIV medicine works as well for women as it does for men. However, some medicines can cause different side effects in women than men. For example, the HIV medicine ritonavir (also called Norvir or RTV) may cause more nausea and vomiting in women. It is sometimes prescribed to help other HIV medicines work better.

HIV medicines can also put women at higher risk than men of getting fat buildup throughout their bodies or of having pancreas problems.

In addition, HIV medicines can interact with other drugs, which can harm you or make your HIV medicines less effective. These include:

Prescribed medications

Over-the-counter medicines

Recreational drugs and alcohol

Herbal remedies

If you are taking HIV medicines and have problems with any side effects or questions about drug interactions, talk to your health care provider or pharmacist to find solutions that work for you. Do NOT cut down on, skip, or stop taking your HIV medicines unless your provider tells you to.

Women's Aging and HIV

Thanks to effective HIV treatment, women with HIV are living longer lives. That also means that as they age, they face the same health problems that many other older women do, such as heart disease, diabetes, high blood pressure, arthritis, and some cancers.

Women with HIV also may face also other health concerns as they age. These include:

Menopause-Women with HIV may enter menopause younger or have more severe hot flashes than women who do not have HIV. Researchers also think the drop in the female hormone estrogen after menopause may affect women's CD4 counts.

Osteoporosis-Osteoporosis is a disease that causes bones to become weak and easy to break. It is a concern for all older women, but especially for women with HIV. Bone loss occurs faster in women (and men) living with HIV than in people who do not have HIV. Some HIV medicines may also increase the risk of osteoporosis.

If you have questions about symptoms of the menopause or about osteoporosis, talk to your health care team.

Heart Disease and HIV

HIV-related heart disease is a leading cause of death among people living with HIV-even when they are on consistent, effective HIV treatment.

The risk of heart attack is especially a concern for women. Women living with HIV are three times more likely to have a heart attack than women without HIV.

Research is underway to learn how factors unique to women with HIV affect heart disease risk and what to do about it.

Pregnancy and HIV

Women with HIV can have healthy pregnancies. But some may need to switch HIV medications. Talk with your provider if you are thinking of planning a pregnancy, including about how to prevent HIV transmission if your partner is HIV-negative.

In addition, women with HIV can pass the virus to their baby during pregnancy, childbirth, or breastfeeding. The good news is that there are ways to lower the risk of passing HIV to your unborn baby to 1% or less and protect your own health.

Infant Feeding and HIV

If you have HIV, the current recommendation in the United States supports shared decision-making between you and your health care provider regarding infant feeding. Taking HIV medicine and keeping an undetectable viral load substantially decreases your risk of transmitting HIV to your baby through breastfeeding to less than 1%. However, the risk is not zero. Properly prepared infant formula or banked donor human breastmilk are alternative options that eliminate the risk of transmission through breastfeeding. If you are pregnant or thinking of becoming pregnant, talk to your health care provider as early as possible about what infant feeding choice is right for you. Learn more.

Birth Control and HIV

# data[].attributes.attachment_link.description
HIV can cause other health problems that are unique to women. Learn how.

# data[].attributes.headline
Young women in sub-Saharan Africa face a high risk of HIV infection ( tier 2, Lori Ashford is a senior policy analyst at PRB, analyzes population data to advance solutions to the challenges facing our world and improve the well-being of people globally.)

# data[].attributes.subject
Young women in sub-Saharan Africa face a high risk of HIV infection ( tier 2, Lori Ashford is a senior policy analyst at PRB, analyzes population data to advance solutions to the challenges facing our world and improve the well-being of people globally.)

# data[].attributes.body
Women contact HIV easily

HIV is spread to more women each year

Contract it at an earlier age and die early

# data[].attributes.attachment_link.readable_text
(March 2002) New data released on World AIDS Day in December revealed a growing but under-reported tragedy: In sub-Saharan Africa, the epidemic's victims are increasingly young and female. The latest global estimates, prepared by the Joint United Nations Programme on AIDS (UNAIDS), show that in sub-Saharan Africa, the region hardest hit by the epidemic, about 8.6 million people between the ages of 15 and 24 are living with HIV or AIDS. Of these, 5.7 million are young women (see table).
Young People Living With HIV/AIDS
Source: UNAIDS, unpublished estimates, December 2001, as cited in K. Kiragu, "Youth and HIV/AIDS," Population Reports (Fall 2001).

These numbers stand in striking contrast to global data on the AIDS epidemic. Worldwide, women account for an estimated 48 percent of adults ages 15 to 49 who are living with HIV or AIDS. In sub-Saharan Africa, where HIV is spread mainly through heterosexual activity, women account for 55 percent of infected adults. Among those ages 15 to 24, however, young women account for 66 percent of those infected. (The figure below shows the disparity in percentages of young people infected, by gender.)
HIV Prevalence Among African Youth
Estimated percentage ranges in selected countries, end 1999
Source: UNAIDS, Report on the Global HIV/AIDS Epidemic (June 2000).

Studies have shown that adolescent girls in this region are between two and six times more likely to contract HIV than their male peers. These girls and women face a whole range of disadvantages that make them especially vulnerable to infection.

Biological factors. Physiological differences between men and women make transmission of HIV through sexual contact more efficient from men to women than vice versa. (During sexual intercourse, a woman has a larger surface area of her genital tract exposed to her partner's sexual secretions than a man does.) The immature reproductive tracts of adolescent girls make them even more susceptible to infection than adult women.

Social dynamics. Commonly paired with older partners who have already been exposed to HIV, girls and young women often lack the knowledge or self-confidence to resist sexual advances or persuade older men to use condoms. Girls are also more likely than boys to be raped or coerced into sex by someone older and more powerful.

Cultural practices. In many societies, parents teach young women to be submissive to men and arrange marriages for their daughters at young ages. In these situations, and when men have multiple wives, newly married young women may contract HIV unknowingly from their sexually experienced husbands. Many women do not bring up the subject of HIV status with their husbands for fear of violence or reprisals. Also, some societies practice wife inheritance, a tradition in which a wife is given to her brother-in-law upon her husband's death. This can expose either partner, if he or she was not already exposed, to HIV infection.

Economic deprivation. Poverty may compel girls and women to offer sex in exchange for money or gifts. And the most impoverished women are the least likely to seek out or have access to services for the prevention or treatment of sexually transmitted infections, including HIV/AIDS.

A Johns Hopkins University report on youth and AIDS published in December 2001 warns that, as the AIDS epidemic spreads, infection will continue to spread to younger age groups as men choose increasingly younger sexual partners. "Many men believe, probably correctly, that younger girls are less likely to be infected with HIV," the authors explain, "while others hold the mistaken belief that having sex with a virgin can cure AIDS."

Reflecting these trends in sexual preferences, young women with HIV are infected on average 10 years earlier than men and, consequently, many will die at younger ages than men. As a result of this situation, the U.S. Census Bureau projects that by 2020 there will be more men of reproductive age than women in the most severely affected countries of sub-Saharan Africa. This imbalance could lead men to seek even younger women, further increasing HIV infection among adolescent females.

In spite of their exceptional vulnerability, millions of young African women are ignorant about HIV/AIDS and how to prevent it. Demographic and Health Surveys from the region show that, among young women, knowledge of at least one preventive measure (such as abstaining from sex or using a condom) ranges from 15 percent in Mozambique to 72 percent in Kenya. In all countries surveyed, young women have lower awareness than their male peers.

Experiences in Uganda and Senegal provide some hope that the epidemic can be brought under control, given adequate commitment. In these countries, governments confronted the epidemic early, with donor support, and launched nationwide information and education campaigns that reached down to the village level, including schools. Unfortunately, this kind of commitment is lacking in most parts of the continent.

AIDS education among young people and promotion of condom use are controversial undertakings nearly everywhere. But many programs have demonstrated effective ways to promote responsible sexual behavior through peer educators and other innovative channels. In particular, health experts are advocating prevention efforts that take into account the distinct social roles and circumstances of men and women. For example, programs can provide information and counseling to young women to help them gain negotiating skills, and to young men to help them resist the social pressures that lead to risky behaviors.

The new figures represent only rough estimates, based on country data that are not yet refined. Nevertheless, they should serve as a wake-up call to policymakers that, to bring the AIDS epidemic under control, much greater focus on young people is needed.

Lori Ashford is a senior policy analyst at PRB.

For More Information

Kiragu, Karungari. "Youth and HIV/AIDS: Can We Avoid Catastrophe?" Population Reports, Series L, No. 12. Baltimore: The Johns Hopkins University Bloomberg School of Public Health, Population Information Program, 2001.

Sass, Justine, and Lori Ashford. Women of Our World 2002. Washington, DC: Population Reference Bureau, forthcoming February 2002.

Joint United Nations Programme on AIDS. AIDS Epidemic Update December 2001. Geneva: UNAIDS, December 2001.

# data[].attributes.attachment_link.title
Young Women in Sub-Saharan Africa Face a High Risk of HIV Infection

# data[].attributes.headline
Women: the face of AIDS in Africa(  Tier 2, Michael Fleshman is a writer for the African Renewal, a web page that addresses current problems and news in Africa.)

# data[].attributes.subject
Women: the face of AIDS in Africa(  Tier 2, Michael Fleshman is a writer for the African Renewal, a web page that addresses current problems and news in Africa.)

# data[].attributes.body
women have sugar daddies to survive

women are more easily prone to the virus

Increase attention towards women and AIDS.

# data[].attributes.headline
HIV/AIDS and Mental Health( tier 3, Organization, No author, focus on the health and well being of future generations)

# data[].attributes.subject
HIV/AIDS and Mental Health( tier 3, Organization, No author, focus on the health and well being of future generations)

# data[].attributes.body
Depression

Brain Damage(Cognitive and Neurological disorders)

Mental Health conditions

# data[].attributes.attachment_link.readable_text
Being diagnosed and living with a serious illness like Human Immunodeficiency Virus/Acquired Immunodeficiency Virus (HIV/AIDS) can have a big emotional impact on your life. The challenges you can face include coping with the reality of living with a chronic illness and having to manage any mental health conditions that may occur. When you have HIV or AIDS, it's important for you to not only take care of your physical health, but to take care of your mental health as well. While not all those living with HIV will face these challenges, for those who do, a thoughtful treatment plan is very important.

HIV/AIDS can increase the risk of mental health conditions

While mental health conditions are common in the United States, those living with HIV have higher rates of mental health conditions than those who do not.

People living with HIV are twice as likely to have depression compared to those without HIV.

People with HIV/AIDS have an increased risk for developing mood, anxiety, and cognitive disorders.

How does HIV/AIDS increase the risk of mental health conditions?

Some stressors that might come with HIV/AIDS are having trouble getting the services you need, managing your HIV medications, having to tell others you are HIV-positive, and facing the stigma associated with HIV/AIDS. Additionally, people with HIV/AIDS may feel depressed as a result of having to make lifestyle changes, coming to terms with the potential for a shortened lifespan, or losing contact with friends and/or family who may not understand the realities of the condition.

Treatments and Therapies

The HIV virus is treated using a combination of medicines called antiretroviral therapy (ART). ART has come a long way over the years and by starting these drugs as soon as you are diagnosed, you will improve and protect your health and protect your sex partners. Starting antiretroviral therapy can affect a person's mental health in different ways.

You may find that beginning treatment and knowing that you can slow the progression of the virus relieves some symptoms of anxiety and depression and gives you a sense of control over your health. Taking this positive step may improve your feelings about yourself and the future.

Finding the right treatment for depression takes time--so does recovery. It is important to be open and honest about all symptoms - mental and physical - throughout your treatment.

Other ways to help yourself

Get involved with a support group.

Spend time with encouraging people, such as family members and friends and talk about your feelings.

Find activities that relieve your stress, such as exercise or hobbies; learn relaxation methods like meditation, yoga, or deep breathing.

Eat small, healthy meals throughout the day; limit the amount of caffeine you consume.

Get enough sleep each night to help you feel rested.

Mental health screening can help

Research suggests integrating behavioral health services, such as screening, with primary HIV care to allow for a more effective treatment outcome. Screening provides a quick and easy way to spot the first signs of serious illnesses and initiates the connection to care during the early stages. Take a screen at https://screening.mhanational.org/

If you or a loved one is in a mental health crisis, please either visit your local Emergency Room, call 911, reach out to The National Suicide Prevention Lifeline's 24 hour toll-free crisis hotline, 1.800.273.TALK (1.800.273.8255), or text "MHA" to 741741 to receive text-based crisis help.

U.S. Department of Health and Human Services, National Institutes of Health (2019). HIV and Mental Health.

U.S. Department of Health and Human Services, National Institutes of Mental Health (2016). HIV/AIDS and Mental Health. Retrieved from https://www.nimh.nih.gov/health/topics/hiv-aids/index.shtml

Cohen, S., Janicki-Deverts, D., Doyle, W. J., Miller, G. E., Frank, E., Rabin,B. S., Turner, R. B. (2012). Chronic stress, glucocorticoid receptor resistance, inflammation, and disease risk. Proceedings of the National Academy of Sciences . DOI: 10.1073/pnas.1118355109

Whitney, N. P., Eidem, T. M., Peng, H., Huang, Y., Zheng, J. C. (2009). Inflammation mediates varying effects in neurogenesis: relevance to the pathogenesis of brain injury and neurodegenerative disorders. Journal of Neurochemistry , 108 (6), 1343-1359. Retrieved from https://doi.org/10.1111/j.1471-4159.2009.05886.x

U.S. Department of Health and Human Services, National Institutes of Mental Health, National Institute of Neurological Disorders and Stroke (2018). Neurological Complications of AIDS Fact Sheet.

Pence, B. W. (2009). The impact of mental health and traumatic life experiences on antiretroviral treatment outcomes for people living with HIV/AIDS. Journal of Antimicrobial Chemotherapy , 63(4), 636-640. Retrieved from https://doi.org/10.1093/jac/dkp006

# data[].attributes.attachment_link.description
Being diagnosed and living with a serious illness like Human Immunodeficiency Virus/Acquired Immunodeficiency Virus (HIV/AIDS) can have a big emotional impact on your life. The challenges you can face include coping with the reality of living with a chronic illness and having to manage any mental health conditions that may occur.

# data[].attributes.headline
Perceived risk of HIV infection and mental health in rural Malawi( tier 1, Ning Hsieh, author for Jstor who write health articles and prevention)

# data[].attributes.subject
Perceived risk of HIV infection and mental health in rural Malawi( tier 1, Ning Hsieh, author for Jstor who write health articles and prevention)

# data[].attributes.body
Perceived risk of getting effected has a negative effect on mental health

Lack of health care resulted in deteriorated health and quality of life.

incurable leads to anxiety and depression since it can lead to death.

# data[].attributes.attachment_link.title
Perceived risk of HIV infection and mental health in rural Malawi on JSTOR

# data[].attributes.attachment_link.description
Ning Hsieh ¹, Perceived risk of HIV infection and mental health in rural Malawi, Demographic Research, Vol. 28 (JANUARY - JUNE 2013), pp. 373-408

# data[].attributes.headline
People In Sub-Saharan Africa Rate Their Health And Health Care Among Lowest In World( tier 1, Angus Deaton Senior Scholar and the Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at the Princeton School of Public and International Affairs and the Economics Department at Princeton University) 

# data[].attributes.subject
People In Sub-Saharan Africa Rate Their Health And Health Care Among Lowest In World( tier 1, Angus Deaton Senior Scholar and the Dwight D. Eisenhower Professor of Economics and International Affairs Emeritus at the Princeton School of Public and International Affairs and the Economics Department at Princeton University) 

# data[].attributes.body
lowest health care compared to other regions.

health care not prioritized

after COVID a decline in health services such as maternal and child health

# data[].attributes.attachment_link.readable_text
Health Aff (Millwood). Author manuscript; available in PMC 2017 Nov 7.

Published in final edited form as:

Abstract

The health of people in sub-Saharan Africa is a major global concern. However, data are weak, and little is known about how people in the region perceive their health or their health care. We used data from the Gallup World Poll in 2012 to document sub-Saharan Africans' perceived health status, their satisfaction with health care, their contact with medical professionals, and the priority they attach to health care. In comparison to other regions of the world, sub-Saharan Africa has the lowest ratings for well-being and the lowest satisfaction with health care. It also has the second lowest perception of personal health, after only the former Soviet Union and its satellites. HIV prevalence is positively correlated with perceived improvements in health care in countries with high prevalence. This is consistent with an improvement in at least some health care services as a result of the largely aid-funded rollout of antiretroviral treatment. Even so, sub-Saharan Africans do not prioritize health care as a matter of policy, although donors are increasingly shifting their aid efforts in sub-Saharan Africa toward health.

Africa is the continent with the highest mortality rates, and it is the only continent where deaths from infectious disease still outnumber deaths from chronic disease.[ 1] As documented below, spending on health care in sub-Sarahan Africa is low. A typical figure is around $100 per capita in 2005 price-adjusted terms, about half of which is spent in the private sector.

A large share of Western aid to developing countries goes to sub-Saharan Africa. In addition, the region's share of Western aid increased from 29 percent in 1978-79 to 41 percent in 2008-09.[ 2]

Aid to sub-Saharan African countries has increasingly been targeted toward health.[ 3] The region experienced remarkable gains in life expectancy after 1950. However, in the countries that were most seriously affected by the HIV/AIDS epidemic, much or all of the gain was lost by 2000.[ 4]

Recently-especially since 2005, with help from the US President's Emergency Plan for AIDS Relief (PEPFAR) and from the Global Fund to Fight AIDS, Tuberculosis, and Malaria-antiretroviral therapy has become more widely available. According to the Joint United Nations Programme on HIV/AIDS (UNAIDS), 9.7 million people (out of nearly 30 million eligible) were receiving antiretroviral therapy in low- and middle-income countries by December 2012.[ 5] At the same time, and especially in the last decade, there have been marked reductions in infant and child mortality in sub-Saharan Africa.[ 1]

Africa is also the continent with the poorest health data. Few African countries have complete vital registration systems. In addition, in contrast to the situation in high-income countries, there is a dearth of information on how Africans perceive their own health. The Afrobarometer surveys (see http://www.afrobarometer.org), which cover thirty-five countries, are an important resource for people's opinions on governance, public-sector performance, and the priority that people attach to public health care. But these surveys provide little information about how people perceive their own health.

The Gallup Organization has been collecting data in sub-Saharan Africa since 2005, as part of its World Poll.[ 6] We used this rich resource to investigate perceptions of health and health care in the region in 2012. We also used the poll to compare outcomes in sub-Saharan Africa with those in other regions of the world.

We were also interested in the much-debated question of how the HIV/AIDS epidemic has affected people's perceptions of health and health care. There is good evidence that, in the early days of the epidemic, the countries that were most affected by HIV/AIDS experienced declines in other health services, such as maternal and child health care services.[ 7] In these countries there was either an absolute decline in services or a decline relative to what would otherwise have been expected, according to preexisting trends or the situation in unaffected countries.

More recent studies have painted a more complex picture.[ 8, 9] They show that some, but not all, services have seen a rebound since the rollout of antiretroviral therapy.

The evidence is hardly conclusive. However, it is possible that the first phase of the HIV/AIDS epidemic undermined the provision of maternal and child health care as resources were diverted. The subsequent expansion of antiretroviral therapy has been complementary with improvement in some other categories of health provision, such as blood tests. This has not been the case with child immunizations, perhaps because new or renovated facilities for HIV/AIDS patients can be used for multiple purposes.

Study Data And Methods

Our main source of data was the Gallup World Poll, which has been conducted since 2005 in more than 160 countries, and especially the data collected from twenty-eight sub-Saharan African countries in 2012. The poll is a multipurpose survey and is nationally representative in nearly all cases. It uses face-to-face interviews in local languages (fifty-eight languages in sub-Saharan Africa in 2012) to ask 1,000 adults per country ages fifteen and older (2,000 adults in Ethiopia, Nigeria, and South Africa) about various aspects of their lives, including health and well-being, emotions, recent experience with physical pain, life evaluation questions, and their perceptions of health and health care.

The survey also collects sociodemographic data that we used in the analysis below. The online Appendix[ 10] contains a full description of the survey design, as well as the questions used in the analysis.

We also used a range of publicly available data listed in the exhibit notes, such as the World Bank's World Development Indicators[ 11] (for the period 2000-12) and data from UNAIDS[ 5] (for 2012). In addition, we used unit record data-that is, the raw data on individuals and households-from the Demographic and Health Surveys funded by the US Agency for International Development[ 12] to calculate HIV prevalence at the regional level for matching with data from the Gallup World Poll.

Our methods were essentially the tabulation and graphing of data from the surveys. One analysis used multivariate regression to estimate how our measures varied across people with different social and economic characteristics.

Weaknesses of the survey include the inability to ask questions in depth during face-to-face interviews in each country: Questions are limited in scope and number. In the absence of any directly measured health data-such things as height, weight, blood pressure, or blood work-there is no cross-check on self-reports, which is a common problem in community health surveys. Response rates are often a limitation in household surveys, but are not so here; as is typical in poor countries, response rates for the Gallup World Poll are very high. In these African countries in 2012, eighty-four percent of those designated to respond did and the median refusal rate was 6 percent.

Study Results

Sub-Saharan Africa In The Global Context

Sub-Saharan Africans' overall evaluation of their well-being is lower than that of any other population in the world ( Exhibit 1 ). The Gallup World Poll uses the Cantril ladder score as a measure of life evaluation, as explained in the notes to Exhibit 1 . The relevant question in the survey makes no reference to happiness or other aspects of hedonic experience. Thus, it is a clean measure of life evaluation that is distinct from the emotion of happiness. At an average over sub-Saharan African countries of 4.39, -here an unweighted average of the sampling-weighted averages for each of the countries listed in Exhibit 2 -well-being is the lowest in the table.

Exhibit 1

Rating

Region

Well-being

Quality of health care is okay

Unable to do normal activities

Had a lot of physical pain in previous day

Own health is okay

Exhibit 2

Country In

perfect health

Ever seen a medical professional

Health spending per person

Health spending in the private sector

Quality of Health care is okay

HIV prevalence

Comoros

40

- a

59

42

24

0.1

DR Congo

19

87

32

66

32

- a

Ethiopia

52

78

52

42

- a 1.4

Somaliland b

55

48

- a

- a

49

- a

Zimbabwe

35

67

- a

- a

59

14.9

Low well-being is largely a matter of low incomes in sub-Saharan Africa. As previous work has shown,[ 13, 14] there is a nearly linear relationship around the world between average Cantril ladder scores and the logarithm of per capita gross domestic product (GDP). Sub-Saharan African countries are poor, and people in the region understand that their lives are much worse than they might be.

Sub-Saharan Africans are also relatively unhappy with their health care: Only 42.4 percent are satisfied with the availability of quality health care in the city or area in which they live ( Exhibit 1 ). Again, this is the lowest level of satisfaction in the world. In fact, it is less than half of the level for the highest scoring region, the non-English-speaking countries of northern Europe.

A summary of Afrobarometer surveys[ 15] of countries in sub-Saharan Africa reports that 57 percent of respondents say that the government has done well or fairly well at improving basic health services, a percentage that declined between 2002 and 2013. Of course, the questions in the Afrobarometer and Gallup surveys have different wording, and the Afrobarometer surveys cover only publicly provided health care.

The percentages of people who had a health problem that prevented them from doing any of the things people their age can usually do were more equally distributed across the regions of the world ( Exhibit 1 ). That was also the case for the questions about the respondent's physical pain and satisfaction with his or her health. Sub-Saharan Africa is not last in any of these three questions. Nonetheless, the picture of self-reported health in the region is broadly negative.

Health Outcomes In Twenty-Eight Sub-Saharan African Countries

There was an astonishing range of health outcomes across the sub-Saharan African countries surveyed in the 2012 Gallup World Poll ( Exhibit 2 ). The fraction of respondents who reported that they were in perfect health ranged from highs of more than 50 percent in Somaliland and in Ethiopia to only 17 percent in Madagascar and Tanzania. In Ghana, Somaliland, and Sudan, more than half of the population said that they had never had contact with a medical professional. In contrast, in Cameroon, Gabon, and Senegal, the fractions were less than 10 percent.

The cross-country correlation between those in perfect health and those who had never had contact with a medical professional was −0.285. But note that the within-country correlations are small and vary in sign across countries. People in poor health are more likely to seek out medical attention. However, if this were the main reason for the negative cross-country correlation between perfect health and having ever seen medical personnel, it would show up within countries, too. The fact that it does not do so suggests that some other mechanism is at work.

Health spending varied even more widely by country ( Exhibit 2 ). South Africa and Botswana, both relatively wealthy and both with high HIV prevalence, spent $942 and $734 per person, respectively.

The median for all countries was $109 per head, but the Democratic Republic of the Congo, Ethiopia, Madagascar, and Niger spent less than half of that. In any case, $109 a year does not buy much health care. At these levels of spending, there is a correlation of 0 between spending on health care and the fraction of respondents who had ever had contact with a medical professional.

Much of the literature on health in poor countries focuses on the provision of health care by the state.[ 16] This may be because, since the Alma-Ata Declaration of 1978[ 17] established the goal of primary health care for all people, that provision is seen as desirable in itself. At least some of the questions about attitudes toward health care, as in the Afrobarometer, relate to the government's role in providing basic health services.

Yet Exhibit 2 shows that privately provided health care is important in sub-Saharan Africa. In twelve of the twenty-eight countries listed, at least half of all health care spending is in the private sector. And in only one country (Malawi) does the private sector account for less than a third of all health care spending.

The private sector tends to be somewhat more important in places where little is spent overall. The literature[ 16, 18] on health care provision in poor countries suggests that private providers can often deliver as good service as the state where the state has low capacity, especially for routine care. The private provision of health care also does not suffer from the problems of mass absenteeism of health care providers that often mar public-sector provision.[ 18, 19]

Of course, the limited capacity of the state undercuts not only the public provision of health care, but also government regulation of private health care providers. Both public and private providers have distinct strengths and weaknesses.[ 18] Unqualified and unregulated practitioners in the private sector can provide very bad care indeed.

The highest correlation among results in Exhibit 2 (0.51) was between HIV prevalence and the fraction of respondents who approved of the health care system. There was a positive correlation between per capita GDP (in purchasing power parity US dollars) and HIV prevalence. However, the correlation between approval of the health care system and HIV prevalence is not attributable to variations in income: The partial correlation after allowing for the log of GDP per capita was 0.48. It should be noted, however, that the countries with the highest HIV prevalence at the beginning of the epidemic were those with the best-developed health systems.[ 7]

Health Outcomes At The Individual Level

The Gallup data allow a look beneath the aggregate level and show how perceptions and self-reported health and well-being vary across age, sex, income level, and other variables. The results (presented in detail in the Appendix)[ 10] are predictable in some cases but also contain some surprises.

The effects of age on life evaluation provide the first surprise: The average life evaluation did not differ by age in sub-Saharan African countries. This is in sharp contrast to the famous U-shape age profile of life evaluation in the United Kingdom, the United States, and other high-income English-speaking countries of the world. In those countries, early and later years are evaluated highly, with the lowest levels of well-being occurring in the middle years.[ 20]

One possible explanation for the U-shape profile is that it occurs only in countries where there are strong social security systems and programs that provide health care coverage for the elderly-which is certainly not the case in sub-Saharan Africa. Yet the other variables considered in this analysis were correlated with well-being in similar ways to correlations in high-income countries. For example, women evaluated their lives more highly than men, and income and education brought greater well-being, with a coefficient in line with the situation in other countries.[ 21]

Compared to single or married people, those who were divorced, separated, and widowed people (the "other" category of marital status) reported lower levels of well-being. Similarly, people with two or more children living in the household reported lower well-being than people with one or no children at home.

We also examined the correlates of two measures of self-reported health, in which the respondent reported whether he or she was in perfect health and whether his or her health was satisfactory. These two questions are posed separately, and both are distinct from the question about whether or not health care was satisfactory.

Not surprisingly, in sub-Saharan Africa, both measures declined with age. However, perfect health deteriorated more rapidly at young ages, while satisfactory health deteriorated more rapidly at older ages. Better off, more educated, and more religious people (those who reported that religion was very important in their lives) were in better health, compared to women and those who were widowed, separated, or divorced.

Confidence in sub-Saharan African health care systems (the "health care is okay" variable in Exhibit 2 ) varied sharply by country. However, within countries there was very little variation by age or marital status. Women, people with more education, and those with higher incomes had more confidence in their country's system, compared to men, those with less education, and those with lower incomes. [please provide]. This is surprising, because the groups with more confidence are also more likely to experience health care and-one might have thought-to understand its weaknesses. Perhaps they simply have limited experience with which to compare.

There was a huge cross-country variation in the numbers of people who ever had contact with the medical system in sub-Saharan African countries ( Exhibit 2 ). In addition, our regression analysis shows that the probability of ever having had contact with a medic or other health care provider in the system increased with age. The probability was also higher for women and for people who were married, had children, were more educated, or were more religious, compared to men, those who were not married, had no children, were less educated or were less religious. The relationship between being religious and having had contact with the medical system may reflect the role of religious institutions in providing health care in much of the region.

Perceptions Of Health Care And The HIV/AIDS Epidemic

One controversial issue in both the literature and the donor community is the effect of the HIV/AIDS epidemic on health care, both before and after the dramatic increase in aid after 2004 from PEPFAR and the Global Fund. This issue has been studied over a range of periods.[ 7- 9]

Perhaps the most obvious story here is that, before the aid for the disease, HIV/AIDS simply put additional strains on already weak health care systems, undermining previously provided services such as those related to mother and child health. With the inflow of funds from PEPFAR, the Global Fund, and other donors after 2004, that undermining might have been reversed if the expanded facilities and numbers of medical personnel were used not only for the delivery of antiretroviral therapy, but also for other services.

A more negative possibility, which has been a concern, is that new services displaced old ones-for example, by bidding nurses away from what they had previously been doing in some countries.[ 8] A 2014 study[ 9] paints a relatively positive picture, with mother and child health services improving in the affected regions and countries after 2004.

Blood tests for pregnant women are now routinely given to prevent mother-to-child transmission of the virus, and this has certainly led to an increase in blood tests and possibly in some other antenatal services. For both Karen Grépin[ 8] and Josephine Duh,[ 9] the effects differ for different kinds of service provision.

The most relevant question in the Gallup World Poll is whether the respondent believes health care has improved over the previous five years. The respondent can answer "yes," "stayed the same," or "got worse": We coded the three responses as 1, 0, and -1. Exhibit 3 plots the average score for perceived improvement in health care against the HIV prevalence estimates reported in Exhibit 2 . Note first that in all of the countries except Sudan and Tanzania, people thought that the quality of health care had increased over the previous five years.

The correlation between perceived change in the quality of health care and HIV prevalence is only 0.21, which is not significantly different from zero. Thus, according to these measures, people's perception of whether or not health care had improved did not vary according to the level of HIV prevalence in their country.

The results for individual countries are also interesting. Botswana is a case in which high HIV prevalence brought substantial improvements in health care and this shows up clearly in Exhibit 3 . Similarly, among the countries with an HIV prevalence of at least 5 percent-Botswana, Gabon, Kenya, Malawi, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe-there was a positive relationship between prevalence and perceived improvement in health care. The fact that there was no overall positive correlation is because, among the countries with a low prevalence, a wide range of health care improvements came about through other factors.

The Gallup World Poll also asks respondents their expectations of health care improvement in the following five years. The results for this variable-which we also coded 1, 0, or -1-were higher on average than the perception of health care in the previous five years: 47 percent expected net improvements, as opposed to only 36 percent who reported seeing improvements in the previous five years. Even so, there was a high cross-country correlation between the past and the future. Expectations about future improvements in health care were no more correlated with HIV prevalence than were the perceptions of past improvements.

In summary, there is no evidence in Exhibit 3 that countries with high HIV prevalence had any systematic decline in the quality of health care in 2007-12. If anything, the reverse seems to be true, at least among the countries most affected by HIV. And note again from Exhibit 2 that the countries with high HIV prevalence were also those with the highest fraction of respondents who were satisfied with the quality of their health care in 2012, a correlation that is significant. All of this gives a mildly positive picture of the relationship between health care perceptions and HIV prevalence, at least in the most recent years.

To check that these findings were not confounded by a relationship between economic growth and improvements in health care, we used World Bank data on the rate of growth of GDP per capita from 2000 to 2012, as well as the separate growth rates from 2000 to 2005 and from 2005 to 2012. None of the growth rates had a significant correlation with perceptions of health care improvement.

In many of the affected countries in sub-Saharan Africa, the HIV prevalence rate varies within countries by region. These regional HIV prevalence rates within countries can be estimated from successive rounds of the Demographic and Health Surveys, in some of which respondents are administered tests for the HIV virus so that their measured HIV status does not depend on what they themselves know. We used the prevalence estimates for the subset of regions that we could match to the regional information in the Gallup World Poll, which gave us 140 observations from fifteen countries between 2003 and 2012. Of the 140 regions, 86 were observed in the four-year period 2009-12. For these regions, we calculated the average HIV prevalence rates of people ages 15-49, which is the age range of respondents in the Demographic and Health Surveys.[ 12]

Clearly, these data-with their age restriction, limited number of countries, and range of years-are less than perfect. However, having 140 observations as opposed to only 24, which is the case in Exhibit 3 , gave us a better chance of observing any patterns that exist.

Exhibit 4 presents more details than Exhibit 3 does, although some countries in Exhibit 3 -including Botswana-are missing from Exhibit 4 . Exhibit 4 confirms the overall lack of a pattern when all regions in all countries are pooled. Furthermore, as in Exhibit 3 , there is a suggestion of a negative relationship between perceived improvements in health care and HIV prevalence where the prevalence is low, and of a positive relationship in the regions with high HIV prevalence.

We examine the relationship within countries by running the regression on the data in Exhibit 4 with the addition of country dummies, there was a negative but insignificant relationship between whether health care was perceived to have improved and the rate of HIV prevalence. We examined whether this relationship was different when we accounted for education (which was positively correlated with HIV prevalence) and urbanization (which was uncorrelated with HIV prevalence in the data shown in Exhibit 4 ). However, the presence of these two factors in the regression had little effect.

In summary, one explanation for the data in Exhibit 4 is that [please provide] a high rate of HIV prevalence in the population by itself reduced the perceived effectiveness of the health care system. We can see this negative relation in the countries with low HIV prevalence today, just as was the case in all countries in the early years of the epidemic.

In recent years, however, countries with high HIV prevalence have attracted a great deal of health-related aid, which may have helped improve their citizens' perceptions of their health care systems. Exhibit 4 also shows some evidence that, within countries with high HIV prevalence-such as Tanzania, Zambia, and Zimbabwe-there was a negative relationship across regions within each country between perceived improvement and HIV prevalence. That would be the case if health aid were not well allocated within countries.

Sub-Saharan Africans' Perceptions Of Their Most Urgent Needs

Health aid to sub-Saharan Africa from high-income countries has recently increased much more rapidly than nonhealth aid. However, there have been occasional questions about whether this is a response to sub-Saharan African demands or is something that the richer countries are choosing to do for reasons of their own. The latter view has been argued in general by Angus Deaton,[ 4] and more specifically, using Afrobarometer data, by Homi Kharas[ 22] and Benjamin Leo.[ 3]

The Gallup World Poll asks respondents to name the issues that should be the highest priority for their government. Respondents are presented with the following options: health care, education, providing new jobs, improving agriculture, providing electricity, and tackling corruption. Health care is not the highest priority, which is also the case in the Afrobarometer surveys.[ 3, 22] Averaged over all sub-Saharan African countries (with each country equally weighted), 31.0 percent of people picked new jobs as their top priority, and 21.0 percent picked improving agriculture. Tackling corruption was next, at 14.4 percent. Education and health care were chosen by 13.6 and 13.5 percent of the respondents, respectively. Providing electricity was picked by only 6.3 percent.

When we examined the correlation between these preferences, we found that people who prioritized agriculture also prioritized new jobs. This suggests that these choices share an underlying factor, the importance of better livelihoods.

We also found a strong negative correlation across countries between prioritizing health care and HIV prevalence as listed in Exhibit 2 . Countries with the highest HIV rates had the most advanced health care systems at the start of the epidemic.[ 3] As a result, people in those countries may feel that their governments are already paying enough attention to health care.

The 2012 Gallup World Poll did not ask about HIV/AIDS as a priority. However, when that question was asked in a previous survey, it ranked third- after poverty reduction and hunger reduction and ahead of providing more jobs, reducing child mortality, reducing maternal mortality, and improving education.

Of course, just because people in sub-Saharan Africa do not see health care as the highest priority does not mean that aid agencies are incorrect to prioritize it. People in the region may be poorly informed (for example, about the possible effects of better health care on their health and thus on their livelihoods) or, after centuries of high morbidity, they may not believe that the government (or anyone else) is capable of providing any meaningful relief. But even if they are well informed, it might also be the case that aid agencies believe-correctly or incorrectly-that they are more effective at saving lives than at generating economic growth.

Conclusion

We used data from Gallup's World Poll to examine how sub-Saharan Africans perceive their well-being, health, and health care systems. The people of the region rate their well-being lower than do the people of any other region in the world. The same is true of sub-Saharan Africans' perception of the health care that they receive. Even so, people in the region do not feel that improving health care should be the highest priority for their governments. Nonetheless, donors are increasingly focusing their aid efforts in sub-Saharan Africa on health.

Does HIV prevalence make health care even worse? Our results suggest that this is likely true, except where HIV prevalence is highest. In these heavily affected countries, there may well have been positive spillovers from external funding for HIV into the more general health care system.

Acknowledgments

Angus Deaton's work is supported by the Gallup Organization and by the National Institute of Aging through both the National Bureau of Economic Research (Grant Nos. 5R01AG040629-02 and P01 AG05842-14) and Princeton University's Roybal Center for Translational Research on Aging (Grant No. P30 AG024928). Deaton is a consultant to the Gallup Organization. The authors are grateful to Anne Case for comments on earlier versions and to Josephine Duh for comments and assistance with the regional HIV prevalence data from the Demographic and Health Surveys.

Biographies

Angus S. Deaton ( ude.notecnirp@notaed) is the Dwight D. Eisenhower Professor of International Affairs and Professor of Economics and International Affairs at the Woodrow Wilson School, Princeton University, in New Jersey.

Robert Tortora was principal scientist and chief methodologist at the Gallup Organization, in Washington, D.C., when this article was written. He is now a Senior Fellow of Survey Methodology at ICF International in Rockville, Maryland.

Contributor Information

Angus S. Deaton, Princeton University, Princeton, NJ.

Robert Tortora, Gallup Organization, Washington, DC.

Notes

4. Deaton A. The great escape: health, wealth, and the origins of inequality. Princeton (NJ): Princeton University Press; 2013. [ Google Scholar]

10. To access the Appendix, click on the Appendix link in the box to the right of the article online.

14. Stevenson B, Wolfers J. Economic growth and subjective well-being: reassessing the Easterlin paradox. Washington (DC): Brookings Institution; 2008. (Brookings Papers on Economic Activity). [ Google Scholar]

16. Filmer D, Hammer JS, Pritchett LH. Weak links in the chain II: a prescription for health policy in poor countries. World Bank Res Obs. 2002;17(1):47-66. [ Google Scholar]

18. Das J, Hammer J. Which doctor? Combining vignettes and item response to measure clinical competence. J Dev Econ. 2005;78(2):348-83. [ Google Scholar]

# data[].attributes.attachment_link.title
People In Sub-Saharan Africa Rate Their Health And Health Care Among Lowest In World

# data[].attributes.attachment_link.description
The health of people in sub-Saharan Africa is a major global concern. However, data are weak, and little is known about how people in the region perceive their health or their health care. We used data from the Gallup World Poll in 2012 to document sub-Saharan ...

# data[].attributes.headline
Doctors and nurses with HIV and AIDS in sub-Saharan Africa(Tier 1, Dan J Ncayiyana, vice chancellor of the Durban Insititute of Technology in South Africa)

# data[].attributes.subject
Doctors and nurses with HIV and AIDS in sub-Saharan Africa(Tier 1, Dan J Ncayiyana, vice chancellor of the Durban Insititute of Technology in South Africa)

# data[].attributes.body
not enough health workers( workers are decreasing/ becoming infected)

The health system is decreasing due to absentee, illness, over patient load.

A supportive work environment was met with denial

# data[].attributes.attachment_link.title
Doctors and nurses with HIV and AIDS in sub-Saharan Africa: “We’re going to run out of people before we run out of money”

# data[].attributes.attachment_link.description
Much has been written about the impact of the HIV and AIDS pandemic on the healthcare delivery systems and resources in central and southern Africa. The unremitting pressure on hospitals and other healthcare facilities,1 and the disproportionate use of healthcare resources by the ever increasing numbers of patients, are threatening to undermine the capacity of countries such as South Africa to provide a comprehensive health safety net for the rest of the population.2

# data[].attributes.headline
Access to HIV healthcare services by farm workers in sub-Saharan Africa (SSA): a systematic review protocol( Tier 1Journal, Nosimilo Mlangeni is a public health specialist. National institute for occupational health; Stellenbosch University)

# data[].attributes.subject
Access to HIV healthcare services by farm workers in sub-Saharan Africa (SSA): a systematic review protocol( Tier 1Journal, Nosimilo Mlangeni is a public health specialist. National institute for occupational health; Stellenbosch University)

# data[].attributes.body
Poor policies

Health Care is not accessible to everyone and isn't in accessible locations for everyone

Farmers don't have health care which can cause them to spread HIV without realizing

# data[].attributes.attachment_link.readable_text
Introduction Sub-Saharan Africa (SSA) region harbours the highest burden of HIV infections in the world. Agricultural work has been reported as one of the occupations with a high prevalence of HIV. Farm workers generally have poor access to health services, which prevents them from receiving proper HIV prevention and care. Furthermore, poor policies and policy implementation, and lack of workplace programmes increases farm workers' vulnerability to HIV infection. Thus, the aim of this study is to conduct a systematic review to assess HIV prevention and treatment services and national policies governing access to healthcare services by farm workers in SSA.

Methods and analysis Our systematic review will include studies published from January 1990 to December 2021 within SSA countries. We will use a sensitive search strategy for electronic bibliographic databases and grey literature sources. Databases will include PubMed, CINAHL, Cochrane library, African Index Medicus and Scopus. The main outcomes to be reported will be HIV policy for farmworkers, availability of HIV prevention service(s), availability of treatment and support to farmworkers who are living with HIV, presence of referral structures for farmworkers through the health system and follow-up services for farmworkers who are on antiretroviral therapy. We will synthesise the main characteristics of included studies and use summary measures to describe study characteristics. In a situation where data are not sufficiently homogeneous to perform a quantitative synthesis, we will conduct a narrative synthesis. We will explore themes and relationships between included studies for qualitative data.

Ethics and dissemination The study will use publicly available data and ethics exemption has been obtained from Human Research Ethics Committees, Faculty of Medicine & Health Sciences, Stellenbosch University. The results of this study will be disseminated through peer-reviewed journals, conference presentations and seminars.

PROSPERO registration number CRD42021277528.

Objectives

The specific objective of this systematic review is to summarise data on HIV services available for farmworkers in SSA, including services provided at the workplace, by private or NGOs, or provided by the ministries of health. The second objective is to assess the presence of policies that guides provision of HIV services to farmworkers at government or workplace level.

Study participants

Studies that report on farm workers' HIV prevention, treatment, care and support, regardless of age or gender, will be included. These will include all categories of farm worker status, be it migrant and non-migrant, as well as seasonal and permanently employed farm workers. For this systematic review 'farm worker' are defined as persons employed to work on a farm regardless of the migration status, and working in full-time employment, seasonal or temporary basis.

Time frame

Studies published from January 1990 to December 2021 within SSA countries will be included. This will ensure that included studies provide up to recent developments in the provision of services. The dates also factor in the emergence of the HIV pandemic and the introduction of ART programmes and services in SSA.

Outcomes

The study will examine outcomes on availability and access to HIV services for farm workers. The main outcomes of interest are the presence of HIV policy frameworks, guidelines or programmes for HIV prevention, treatment and care services, and other treatment modalities specifically targeting farm workers.

Inclusion criteria

Studies conducted on HIV prevention, treatment, care and support for farm workers in SSA. We will include quantitative studies such as case-control studies, cohort studies and cross-sectional surveys. We will also include qualitative studies such as case studies, phenomenological studies and mixed-methods studies. Furthermore, we will review unpublished quantitative and qualitative data obtained from reports and policy documents. We will include articles published in all languages, including but not limited to English, French and Portuguese. We will use language translation software for studies published in other languages other than English.

Exclusion criteria

We will exclude studies that are done outside of SSA. Letters, editorials, reviews and commentaries, will also be excluded. Studies that do not measure, discuss or report any of the prevention levels of HIV services will be excluded. All studies published before 1990 will be excluded.

Search strategy

We will use a sensitive search strategy for electronic bibliographic databases and grey literature sources ( online supplemental file 1). Search terms will be designed for MEDLINE (PubMed) to identify controlled vocabulary of Medical Subject Headings (MeSH) related to HIV and farm workers. We will identify keywords based on our knowledge of the field of HIV infection. MEDLINE search terms will be adapted for other electronic databases to conform to their search functions. Databases will include PubMed via MEDLINE, CINAHL (EBSCO Host) Cumulative Index of Nursing and Allied Health Literature, Cochrane Library, including the Cochrane Central Register of Controlled Trials, African Index Medicus and Scopus.

We will also search the following websites for additional information on HIV services for farmworkers: the SSA Ministries of health for policies and guidelines, the research institutes, the ILO, the WHO and other key non-governmental organizations (NGOs) websites.

Furthermore, we will search grey literature through Google Scholar and Open Grey (SIGLE) for any relevant unpublished work. We will also search for possible additional citations from the reference list, conference abstracts from International Conference on AIDS and STIs in Africa and South African Aids conferences, and presentations using Web of Science Proceedings Citation Index. The search terms will be used in different combinations as per the objective of the review and will include keywords such as HIV/AIDS, HIV workplace service, HIV workplace programme, HIV prevention, HIV policy, mobility and migration, farmworkers' health, migrant farmworkers, migration and health, agriculture, healthcare access, seasonal farmworkers, occupational health and SSA. Search results will be managed and remove duplicates using specialised bibliographic software, Endnote reference management tool ( http://endnote.com/). We will prepare a search diary with details of the databases searched, keywords used and number of search results.

Data extraction, management and selection of eligible studies

Initial screening of titles and abstracts will be undertaken by two reviewers (NM and MM) against the inclusion and exclusion criteria through Rayyan QCRI, the Systematic Reviews web app. 23 Full-text articles will be appraised for relevance and methodological quality by two independent reviewers (NM and MM). Any disagreements on selected articles will be resolved through mutual consensus or involvement of a third reviewer (OA, PN and or ML). Data will be systematically extracted using a standardised data collection tool that will be developed according to the format laid down in the Cochrane Handbook for Systematic Reviews of Interventions. We will extract data about the first author, publication year, journal, language, setting (workplace, private, government services), research methods and outcomes (type of HIV services accessed). The data extraction tool will be piloted by two reviewers (NM and MM) on at least five randomly selected articles prior, thereafter the tool will be revised accordingly based on observations during the piloting process.

We will make attempts to contact study authors for studies that will have missing data on key variables, or where further clarity is necessary. For missing data that cannot be obtained, a description of such missing data with possible implications thereof will be provided in the review.

Data analysis

We will synthesise the main characteristics of included studies and use summary measures to describe study characteristics as described by the primary authors such as the mean, median, proportions and frequencies. We will use descriptive statistics to determine the proportion of included studies that reported the key outcomes. We will assess homogeneity of the study findings and use the χ ² and I ² test to come up with percentage variation across the studies. We will consider I ² value greater than 75% as considerable heterogeneity. Data will be analysed using Stata statistical software, V.16.1. Subgroup analysis will be done to explore sources of heterogeneity in studies, as heterogeneity is mostly in some individual studies due to variations in study designs and methodology. In a situation where data are not sufficiently homogeneous to perform a quantitative synthesis, we will conduct a narrative synthesis.

In analysing qualitative studies, a thematic framework analysis will be conducted following an inductive approach, where themes will be determined through engagement with extracted data. Coding of data will be done based on the themes identified in the data. We will follow five steps of framework synthesis which include familiarisation with the data, identifying a thematic framework, indexing, charting, mapping and interpretation. 24 We will use the Research evidence (SURE) thematic framework 25 to guide our thematic analysis. We will present our findings on a summary of qualitative findings' table that will summarise our key findings.

All findings will be presented following the format recommended by PRISMA-P. 26

Risk of bias in included studies

To assess the risk of bias within included studies, the methodological quality of studies will be assessed by using the Newcastle-Ottawa scale (NOS) which is used for assessing the quality of non-randomised studies in meta-analysis. 27 The NOS for cohort and cross-sectional studies will be modified to meet the systematic review requirements, while the cohort scale will be modified for case studies.

The strength of the body of evidence will be assessed by using the Grading of Recommendations Assessment Development and Evaluation (GRADE) approach. 28 The grade certainty of evidence presented as high, moderate, low and very low will be determined based on an assessment of evidence for risk of bias, publication bias and indirectness. The assessment will be conducted by two reviewers (NM and MM) and where there are disagreements a third reviewer (OA, PN or ML) will be involved to resolve the differences.

To assess our confidence on qualitative findings, we will apply the CERQual approach. 29 This approach draws on the GRADE approach and assesses confidence based on four components: the methodological limitations of included studies, the relevance of the included studies to the review question, the coherence of the review findings and the adequacy of data contributing to the review findings. The confidence findings will be reported as either high, moderate, low or very low. The CERQual assessment will appear in a summary of qualitative findings table.

Patient and public involvement

Patients and/or the public will not be involved in this review.

Ethics and dissemination

The study will use publicly available data, hence ethical approval was no warranted. The findings will be disseminated in scientific forums and conferences targeting public health audiences and policymakers using virtual platforms such as webinars.

Patient consent for publication

Not applicable.

# data[].attributes.attachment_link.title
Access to HIV healthcare services by farm workers in sub-Saharan Africa (SSA): a systematic review protocol

# data[].attributes.attachment_link.description
Introduction Sub-Saharan Africa (SSA) region harbours the highest burden of HIV infections in the world. Agricultural work has been reported as one of the occupations with a high prevalence of HIV. Farm workers generally have poor access to health services, which prevents them from receiving proper HIV prevention and care.

# data[].attributes.headline
Sub-Saharan Africans Rate Their Health and Health Care Among the Lowest in the World( Tier 1, Rose Huber is the Director of Communications & Senior Writer, Office of Public Affairs and Communications in the Princeton School of Public and International Affairs, science writer at the University of Pittsburgh Medical Center)

# data[].attributes.subject
Sub-Saharan Africans Rate Their Health and Health Care Among the Lowest in the World( Tier 1, Rose Huber is the Director of Communications & Senior Writer, Office of Public Affairs and Communications in the Princeton School of Public and International Affairs, science writer at the University of Pittsburgh Medical Center)

# data[].attributes.body
The government was already paying enough to health care before the pandemic

Poor counties already have so many other concerns health care isn't top priority.

# data[].attributes.attachment_link.provider_name
Princeton School of Public and International Affairs

# data[].attributes.attachment_link.readable_text
Sub-Saharan Africans rate their health and health-care systems among the lowest in the world, according to a new report published by Princeton University's Woodrow Wilson School of Public and International Affairs.

Despite these low ratings, health care is not a primary policy concern for people in these countries. Instead, sub-Saharan Africans cite jobs as a top priority, followed by improving agriculture and tackling corruption.

One influence behind such perceptions is the pervasiveness of HIV in certain countries within sub-Saharan Africa, which poses challenges for poorly funded health care systems. But the introduction of Western aid may have swayed certain perceptions: people living in regions with the highest rates of HIV report receiving better health care in the five years prior to 2012 - most likely due to spillovers from foreign funding, the researchers report.

The research - released by Health Affairs as a Web First - points to some of these difficulties of addressing health in general and HIV/AIDs in particular in African nations suffering from chronic poverty, unemployment, corruption and conflict. The confluence of these crises creates many dilemmas: Nations find it difficult to provide adequate health care, and countries with poor health care have so many other immediate problems that for people in those countries, health is often not one of their top concerns.

"Countries with high HIV prevalence have attracted a great deal of health-related aid, which may have helped improve their citizens' perceptions of their health-care systems," said co-author Angus Deaton, Dwight D. Eisenhower Professor of Economics and International Affairs at the Wilson School. "There may well have been positive spillovers from external funding for HIV into the more general health care system. Even so, we find that people in the region do not feel that improving health care should be the highest priority for their governments."

While Africa is the continent with the poorest health data, there is a dearth of information on how Africans perceive their own health. One survey collector is the Gallup Organization, which has been collecting information in sub-Saharan Africa since 2005 as part of its World Poll. Twenty-eight sub-Saharan African countries are included in this survey, which uses face-to-face interviews in local languages to ask residents how they feel about various aspects of their lives.

Deaton and co-author Robert Tortora (who worked at the Gallup Organization when this report was written) used data from the Gallup World Poll along with publicly available data from the World Bank's World Development Indicators, UN-AIDS and the Demographic and Health Surveys, which is funded by the U.S. Agency for International Development. Altogether, these data allowed the researchers to examine health perceptions of sub-Saharan Africans at individual, local and global levels.

Perceptions of Health and Health Care in Africa

The Gallup World Poll uses the Cantril ladder, a measure of wellbeing developed half a century ago by Princeton social researcher Hadley Cantril. This measure asks participants to visualize a ladder with steps numbered from zero at the bottom (worst possible life) to 10 at the top (best possible life).

When calculating wellbeing in sub-Saharan Africa, the researchers find that it is lower than that of any other region in the world. As previous work has shown, the researchers find a strong correlation between average Cantril ladder scores and gross domestic product figures. Simply put, lower incomes translate to lower ratings of wellbeing.

"Sub-Saharan African countries are poor, and people in the region understand that their lives are much worse than they might be," Deaton said.

In terms of health care, only 42.4 percent of sub-Saharan Africans are satisfied with the availability of high-quality care near where they live. Still, 57 percent of people say their government has done well or fairly well at improving basic health services - a percentage that declined between 2002 and 2013. Overall, the researchers report a broadly negative picture of self-reported health in sub-Saharan Africa.

Perceptions of health in sub-Saharan Africa varied by country. The number of people who reported that they were in perfect health ranged from highs of more than 50 percent in Somaliland and Ethiopia to only 17 percent in Madagascar and Tanzania. In Ghana, Somaliland and Sudan, more than half of the population said that they had never had contact with a medical professional. But in Cameroon, Gabon and Senegal, the fractions were less than 10 percent.

Health care spending varied even more widely by country. South Africa and Botswana, both relatively wealthy and with high rates of HIV, spent $942 and $734 per person, respectively. But the median for all countries was $109 per capita. The Democratic Republic of the Congo, Ethiopia, Madagascar and Niger spent less than half of that amount.

Privately provided health care is important in sub-Saharan Africa. In 12 of the 28 countries included in the Gallup World Poll, at least half of all health care spending is in the private sector. Only in Malawi does the private sector account for less than a third of all health care spending.

"The private sector tends to be somewhat more important in places where little is spent overall," said Deaton. "Private providers can often deliver services as good as those the state delivers in places where the state has low capacity, especially for routine care."

When evaluating health and wellbeing perceptions on an individual level in sub-Saharan Africa, the researchers found both predictable and not-so-common results.

The effects of age on life evaluation provided the first surprise: life evaluation did not differ by age in sub-Saharan African countries. This is in sharp contrast to the famous U-shape age profile of life evaluation in richer countries like the United States where life evaluation dips in middle age but then increases with older age.

"One possible explanation is that the U-shape only occurs in countries where there are strong social security systems and programs that provide health care coverage for the elderly, which is certainly not the case for sub-Saharan Africa," Deaton said.

Still, the researchers found some similarities between sub-Saharan Africa and wealthier countries. In both cases, women evaluated their lives more highly than men, and income and education brought greater wellbeing. Likewise, those who were divorced, separated or widowed reported lower levels of wellbeing, and people with two or more kids in the house reported lower wellbeing than people with one or no children at home.

On an individual level, confidence in health-care systems varied sharply by country. Women, people with more education and those with higher incomes had more confidence in their country's system compared to men, those with less education and lower incomes.

"This is surprising because the groups with more confidence are also more likely to experience health care and - one might have thought - to understand its weaknesses," Deaton said. "Perhaps they simply have limited experience with which to judge the adequacy of health care available to them."

With regards to health care exposure, the probability of ever having contact with a health care provider in the system increased with age. It was also higher for women and people who were married, had children, were more educated and were more religious. The correlation between religion and medical exposure might reflect the role of religious institutions in providing health care to the region, the researchers said.

Perceptions of Health Care Needs in Sub-Saharan Africa

One of the controversial issues in the literature and the donor community is the effect of the HIV/AIDs epidemic on health care, both before and after 2004, which saw a large increase in aid, from the U.S. President's Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund.

When asked whether health care has improved over the past five years, public perceptions did not vary according to the level of HIV prevalence in their country - except among the countries where prevalence is highest. In these countries, higher prevalence is associated with more people perceiving improvement.

"It is possible that the first phase of the HIV/AIDS epidemic ... and the subsequent expansion of antiretroviral therapy - which helps to suppress and stop HIV - has been complementary with improvement in some other categories of health provision," Deaton said.

But while health aid has increased to sub-Saharan Africa from high-income countries, residents there do not view health care as a top policy priority. Instead, 31 percent of people picked new jobs as their top concern, and 21 percent picked improving agriculture. Tackling corruption was next at 14.4 percent. Education and health care were chosen by 13.6 percent and 13.5 percent, respectively. Providing electricity was picked by only 6.3 percent.

When drawing comparisons between the groups, the researchers found that the people who prioritized agriculture also valued new jobs. These choices share an underlying factor: the importance of better livelihoods.

Still, when looking for a connection between prioritizing health care and HIV prevalence, the researchers find none. For sub-Saharan Africans, HIV/AIDS ranks third after poverty reduction and hunger reduction - and ahead of providing more jobs, reducing child mortality, among others. As noted, countries with the highest HIV rates also had the most advanced health care systems at the start of the epidemic. Therefore, people there may feel their governments are already paying enough attention to health care.

"Of course, just because people in sub-Saharan Africa do not see health care as the highest priority does not mean that aid agencies are incorrect to prioritize it," Deaton said. "People in the region may be poorly informed or after centuries of high morbidity, they may not believe the government or anyone else is capable of providing meaningful relief. But even if they are well informed, it might also be the case that aid agencies believe - correctly or not - that they are more effective at saving lives than at generating economic growth."

The paper, " People in Sub-Saharan Africa Rate Their Health and Health Care Among the Lowest in the World," was published online Feb. 25 and will be published in the March 2 print issue of Health Affairs.

Deaton's work is supported by the Gallup Organization and by the National Institute on Aging through both the National Bureau of Economic Research (grant nos. 5R01AG040629-02 and PO1 AG05842-14) and Princeton University's Roybal Center for Translational Research on Aging (grant no. P30 AG024928). Deaton is a consultant to the Gallup Organization.

To read more Wilson School research briefs, click here.

# data[].attributes.attachment_link.title
Sub-Saharan Africans Rate Their Health and Health Care Among the Lowest in the World | Princeton School of Public and International Affairs

# data[].attributes.attachment_link.description
Sub-Saharan Africans rate their health and health-care systems among the lowest in the world, according to a new report published by Princeton University's Woodrow Wilson School of Public and International Affairs.Despite these low ratings, health care is not a primary policy concern for people in these countries.

# data[].attributes.headline
Mental health and HIV A Clinical review( Tier 1, Theo Smart, activist and medical writer)

# data[].attributes.subject
Mental health and HIV A Clinical review( Tier 1, Theo Smart, activist and medical writer)

# data[].attributes.body
health care workers may lack training in how to diagnose and manage mental health problems.

Overfilled hospitals are unable to address the mental health of patients

Even During antiretroviral treatment(ART) mental health is being pushed aside as irrelevant.

Mental health is important if patients are to engage in treatment

# data[].attributes.attachment_link.readable_text
Reviewers
With additional reporting by Lance Sherriff
Thanks to: Dr Kimberley Green, Family Health International, Vietnam; Dr Karilyn Collins, Palliative Care Works; Dr Katie Marwick, University of Edinburgh, UK; Dr Anthony Harries, the International Union Against Tuberculosis and Lung Disease; Dr Francois Venter, RHRU, Johannesburg Hospital, South Africa; Dr Graeme Meintjes, GF Jooste Hospital, Cape Town, South Africa; Dr Paul Roux, Grote Schuur Hospital, Cape Town; Dr John Joska, Western Cape Province Programme Manager for HIV Psychiatry, Cape Town; Dr Doug Wilson, Edendale Hospital, KwaZulu Natal, South Africa; Dr Halima Dawood, Greys Hospital, KwaZulu Natal; Dr Riitta Dlodlo, The International Union Against Tuberculosis and Lung Disease, Zimbabwe; Chris Green, Spiritia Foundation, Indonesia; Dr Kevin Bezanson, University of Toronto, Canada; Dr Pamela Collins, Columbia University, New York.

Key points

People with HIV may experience a wide range of mental health problems, which not only affect quality of life but also negatively affect health-seeking behaviour, adherence, retention in care, transmission risk and clinical health.

Studies in the developing world show a high prevalence of psychiatric disorders in people with HIV, most commonly depression, anxiety and substance misuse.

Mental health provision in resource-limited settings is often remote or under-resourced, and many health care workers may lack training in how to diagnose and manage mental health problems.

A range of screening tools for mental health problems exist. At the most basic level, all patients should be asked about mood and feelings of helplessness or depression at each clinic or home visit, in order to identify patients in need of further attention.

The Substance Abuse and Mental Illness Symptoms Screener has been validated specially for use in people with HIV.

When identified, depression can be managed by physicians or clinical officers, but health care workers need to be aware of the potential for interactions between many drugs used in psychiatric treatment and antiretroviral drugs (see tables at end of this edition).

There are many psychotherapeutic approaches which can be provided by trained professionals. Basic counselling can also assist individuals, especially where suffering follows diagnosis or relates to stigma or bereavement.

Mental health care is likely to have greater success when it addresses underlying causes of mental ill-health such as poverty, lack of access to health care, lack of employment opportunities.

More research is needed to establish which interventions are more successful, and to understand the extent to which culturally-specific interventions are needed.

Case study

24 year-old Daya was married and eagerly expecting her first child -but during her third month of pregnancy she tested HIV-positive during a routine antenatal clinic visit.

Distraught and confused, Daya declined a counselling session and rushed home to confront her husband.

He said the test results must be wrong, and refused to visit the health centre for an HIV test because he said it wasn't necessary. So Daya decided to go for a second HIV test at a different health centre but again her results were positive.

On hearing this news, Daya's husband flew into a violent rage, accused her of being a prostitute and severely beat her. Bruised and exhausted, angry and uncertain of the future of her pregnancy and marriage, Daya took an overdose of pills. Her husband took her to the hospital, but looked her in the eyes and told her that their marriage was finished. This was the last time she ever saw him.

Daya recovered from her suicide attempt, and subsequently went to live with her parents for the duration of her pregnancy. She became increasingly withdrawn and tearful, had frequent bouts of insomnia and depressed mood, and continued to think about suicide.

At 37 weeks pregnant, Daya gave birth to a baby girl and named her Chipo.

Chipo's birth didn't resolve Daya's depression. She continued to feel low and was having trouble adequately feeding the infant. She feared that her baby might turn out to be HIV-positive, and occasionally had thoughts about killing both herself and the child.

This case study, excerpted from a joint report from WHO and the World Organization of Family Doctors (WONCA) Integrating mental health into primary care: A global perspective illustrates how a mental health problem (in this case a severe depressive disorder) can develop after an HIV diagnosis (The outcome of Daya's case will be described later in the article).

But for many people with HIV, severe mental health disorders and disabilities -whether depression, psychoses, personality disorders, alcohol/substance misuse or developmental disabilities - precede HIV infection and were actually part of the reason why they became infected in the first place (see below). Without treatment, these problems are likely to persist.

Though data suggest the prevalence of mental disorders varies widely by setting - and may be influenced by difficult life circumstances (psychosocial factors such as poverty, conflict, sexual violence), culture and coping mechanisms, a growing body of data show that HIV/AIDS and mental health issues are often tightly interwoven. And regardless of whether a condition was pre-existing or emerged after becoming HIV-infected, mental health problems can complicate the care and clinical management of people with HIV, by potentially decreasing adherence and increasing losses to follow-up, reducing quality of life, and leading to poorer health outcomes.

"Mental illness, such as depression, adds to immune suppression," Dr John Joska, the Western Cape Province Programme Manager for HIV Psychiatry recently told the Inter Press Service. People with HIV and mental illness "get sicker quicker, then use more health services, need more hospitalisation and have lower quality of life."

In most settings, evidence suggests that people with mental health disorders or disabilities also have less access to HIV services, or at least have poorer health-seeking behaviour - but few health services seem to be addressing the HIV-related needs of the mentally ill.

According to some sources, the overall contribution of mental illnesses to the global burden of disease is growing.

"WHO figures clearly show that the burden [from] depression is likely to increase - so much so that in 2030 this will be the single biggest cause for burden, out of all health conditions," Dr Shekhar Saxena of the Department of Mental Health at the WHO, told the BBC World Service at the start of the first Global Mental Health Summit held in Athens, Greece, in the beginning of September.

While this projection may be subject to debate, Dr Saxena's other point is not: a mental health problem, such as "depression is as much of a disease as any other physical disease that people suffer from and they have a right to get correct advice and treatment within the same health care settings which look after other health conditions."

Attending to mental health issues should be an essential component of holistic palliative care offered to people with HIV (and their families). The palliative care approach aims to alleviate a person and their family's pain and suffering over the entire course of illness, whether due to HIV's physical effects or the emotional, psychological, and spiritual suffering associated with HIV. People with HIV are more than just lab tests or physical symptoms that need to be treated - there will always be a psychological dimension to their suffering that needs to be assessed and managed. In many cases, this goes well beyond 'distress' and becomes an illness of its own.

"The diagnosis and treatment of psychiatric disorders is essential to the well-being of a person infected by HIV. Appropriate mental health care is also essential if patients are to engage in treatment and sustain sobriety and protective sexual practices," wrote Dr Marshall Forstein in A Clinical Guide to Supportive and Palliative Care for HIV/AIDS . ¹ He added, "it is never appropriate to assume that a psychiatric symptom is merely an "understandable" emotional reaction to a particular situation."

Addressing these needs may be challenging however, because mental health has long been a neglected matter in most resource-limited settings and there may be little infrastructure and training to deal with it. In the World Health Report 2001, WHO estimated that 450 million people worldwide are directly affected by mental, behavioural, neurological and substance use disorders - and most of these people are living in developing countries. ² Approximately one in four people visiting a health service has at least one mental health issue but most of these are neither diagnosed nor treated. This is because "most middle and low-income countries devote less than 1% of their health expenditure to mental health, according to WHO'S Department of Mental Health and Substance Abuse.

"Unfortunately, mental illness is not seen as an integral part of care for people on antiretroviral treatment (ART). As a result, patients are under-diagnosed and under-treated," Dr Joska said in the Inter Press Service article.

A quick survey of HATIP's advisory panel suggests that most HIV programmes have only limited capacity to recognise and manage these conditions:

"In Malawi, the ART clinics are so busy and run by paramedical officers and nurses that I really do think mental health problems get missed and are not well dealt with," Dr Anthony Harries, of the International Union Against Tuberculosis and Lung Disease(formerly with the Ministry of Health in Malawi) told HATIP, adding, "there is one mental health specialist for the whole country."

"Mental health issues are huge in our patients," said Dr Doug Wilson of Edendale Hospital, in KwaZulu Natal, South Africa. But "the mental health infrastructure is severely under-funded, while support services for families and partners fall on overworked social workers."

"Mental health problems are undiagnosed and often impact on adherence but we only detect the non-adherence and do not address mental health adequately," Dr Halima Dawood of Greys Hospital in KwaZulu Natal told HATIP. "We don't have adequate staff in terms of psychologists and Psychiatry only sees the patient as outpatients or after 48 hours of hospitalisation. This is an unsatisfactory arrangement. And services for families and bereavement counselling are almost absent at my site-it is the exception rather than the rule."

"Mental health issues are important especially for us in Zimbabwe where depression, stress and feelings of hopelessness are frequent among all people, whether HIV-positive or not, due to our continued suffering," said Dr Riitta Dlodlo, also of the Union.

And yet, consistently, panellists suggested that busy clinicians have too little time to manage these issues adequately.

"One of the most challenging issues in Malawi was and is just time," Dr. Kevin Bezanson of the University of Toronto, the Temmy Latner Centre for Palliative Care told HATIP. Dr Bezanson was formerly stationed in Malawi. "In the context of a public health approach, the numbers are overwhelming and these issues take time to identify and address well."

"Doctors tend to rely on counsellors to address problems that they have no time to deal with," said Chris Green of the Spiritia Foundation in Indonesia, "but the counsellors are rarely trained for anything other than pre- and post-test counselling."

But a growing number of experts are insisting that it doesn't have to be this way - that mental health can be incorporated into primary health care and that HIV programmes may be the logical first place to start. By integrating mental health into relevant guidelines and "ensuring adequate training in basic medical and psychological management of disorders, a holistic and integrated primary mental healthcare approach can be promoted," wrote Dr Melvin C Freeman and colleagues back in 2005. ³ "Moreover, we believe that, in the case of HIV/AIDS, there is already a substantial human resource base among the primary care providers who are ideally placed to provide front-line mental healthcare in the '3 by 5' initiative... HIV/AIDS counsellors."

With "additional training and relevant materials" Freeman et al argue, it should be possible to integrate "psychiatric and psychosocial interventions that should benefit both the mental and the physical health of people living with HIV/AIDS."

"As the roll-out of antiretrovirals to people living with HIV/AIDS continues to increase in South Africa, so too does the need to integrate mental health services into HIV care," Dr Joska and colleagues wrote in the South African Journal of Psychiatry in 2008. ⁴ "Screening tools for mental disorders are both available and feasible and should be incorporated into routine ARV care, with support from dedicated HIV mental health services."

A global movement to push this agenda has begun. Two years ago, there was a series of articles in The Lancet , one of which declared that in addition to the morbidity and mortality directly attributable to mental disorders, they are so intimately linked with other health problems such as HIV and other chronic conditions, that "there can be no health without mental health." ⁵ With the launch last year of the WHO Mental Health Gap Action Programme (mhGAP), there is increasing political pressure to improve mental health services available in low- and middle-income countries.

An overview of the mental health disorders commonly reported in people with or affected by HIV

Mental health issues commonly seen in people with HIV range from mild distress to frank clinical conditions. This issue will deal primarily with psychological/psychiatric conditions, as previous issues of HATIP addressed neurological conditions, such as HIV-associated dementia or neurocognitive disorders that arise as a consequence of HIV infection or opportunistic infections in the brain (see HATIP January 2007 part 1 and part 2 for an overview of these subjects).

However, many symptoms of certain psychological disorders overlap with neurological problems, which may need to be considered in the differential diagnosis.

Mental disorders have been defined and classified by diagnostic systems like the International Classification of Disorders, 10th Edition (ICD-10) 's Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines, and the American Psychological Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), neither of which are freely available, though a very handy summary of the DSM-IV is available online at http://allpsych.com/disorders/dsm.html. Both systems are due to be updated within the next several years.

While there's a fair amount of agreement between the two systems, some conditions are categorised differently. But in both systems, the classifications themselves are somewhat reductionist, in other words, some of the distinctions between categories seem artificial, and diagnoses often overlap with each other - some critics argue that psychopathology should rather be seen as a spectrum of symptoms. ⁶

Since there are, as of yet, no lab tests for psychiatric or psychological disorders, these diagnostic systems and definitions must be the product of expert consensus (and a review of previous versions of the diagnostic systems show that the expert consensus evolves substantially with each iteration). This brings up another important issue: the experts are mostly drawn from industrialised societies, and what may be considered to be disruptive or abnormal behaviour in one society may not be in another. Some have accused the diagnostic systems of being ethnocentric or culturally biased, and there seem to be some data to support this. 7, 8, ⁹

Increased research in different societies and cultures is needed to help make these diagnostic systems more global.

So, while there are ongoing debates about how some of the disorders ought best to be defined, the following list focuses on some of the important features of the disorders that are most commonly reported in people with HIV in the medical literature, including serious pre-existing problems that could potentially increase vulnerability to HIV, as well as conditions that result from HIV diagnosis and illness for both the person with HIV and their family.

[Unless otherwise noted, the following section is derived primarily from the following sources 10,11,12,13as well as the summaries at http://allpsych.com/disorders/dsm.html].

Depression

Everyone gets depressed at some point in his or her life; and as a symptom, depression is part of many psychiatric conditions. However, the classification systems differentiate between depressive mood disorders, including major depression (sometimes called clinical or endogenous depression), dysthymia (a chronic but less severe low mood lasting more than two years), and adjustment disorders with depression (having difficulty adjusting to an event or stress in life), sometimes referred to as demoralisation.

Major depressive disorder (MDD) is characterised by a persistent low mood, low self-esteem, decreased energy, and a loss of interest or pleasure in normally enjoyable activities. There can also be sleep disturbances (increased sleep or insomnia and fatigue), changes in appetite (with weight gain or weight loss) and thoughts of suicide. MDD disrupts a person's work, family and social life; mood may be so low that there may be a loss of facial expressions, slow psychomotor responses, difficulty concentrating, with memory problems (the condition is sometimes mistaken for HIV-related dementia). In some people, low mood may present as anger or irritability or utter lack of emotion; they may also have delusions of being persecuted.

Biological, psychological, and social factors may contribute to the development of MDD. It may in fact be triggered by a life event like an adjustment disorder but becomes established in such a way that psychiatrists believe it should be seen (and treated) as a brain disease (something like a chronic chemical imbalance in the brain).

Some studies suggest that suicidal ideation may be particularly common in people with HIV, especially if they lose family support or as they develop symptoms.

Adjustment disorder depression or demoralisation commonly occurs following an HIV diagnosis, the break down of a relationship, bereavement due to the loss of a loved one from HIV or other difficult life circumstances, especially when there is inadequate support for an individual. Adjustment depression can be quite severe - people may at times become overwhelmed by sorrow- and difficult to distinguish from MDD in an HIV clinic setting. According to Treisman et al, the condition is less likely to be associated with a negative self-image or ideas of suicide - while people with major depression are more likely to have completely lost any sense of enjoyment from activities that were previously pleasurable. Such symptoms may also be helpful in distinguishing depression from HIV-related cognitive impairment.

Post-partum/natal depression tends to occur within the first six months after delivery that persists more than a couple of weeks. Affected mothers may feel despondent, inadequate, unable to care for their infant, irritable or tearful.

Efavirenz, antiretrovirals and depression: The anti-HIV drug efavirenz ( Sustiva, also in the combination pill ) has been reported to cause or aggravate underlying psychological problems. Some people have difficulty sleeping, or vivid dreams or nightmares. Other people have reported the emergence of depression without any other apparent cause. A large French study has disputed these reports, noting the high burden of pre-existing psychiatric problems among people with HIV. Nevertheless, concerns persist. ¹⁴ Other antiretroviral drugs have occasionally been cited as the causes of psychiatric conditions such as mania, depression and anxiety. However the extent to which other antiretroviral drugs might affect mental health is still poorly characterised despite nearly 15 years experience of their use in combination therapy.

A note about end of life depression and bereavement: "Even at the end of life, depression is a disorder that requires treatment, and should never be considered a normal response to illness or dying," wrote Dr Forstein. Depression at this stage may be associated with emotional flattening and withdrawal from loved ones but should be distinguished from grief. "While sadness may be present in both conditions, grief is a normal reaction to loss or impending loss. Further, grief may manifest differently across cultures.... Grief, however, is often accompanied by powerful and profound affective states and crying, while severe depression appears more like an emotional paralysis, with patients often unable to mobilise any affect other than hopelessness." Another palliative care resource, suggests that, "the presence of suicidal ideation and inappropriate guilt may help to differentiate the two." ¹⁵

Of course, death also has a profound impact on one's loved ones. According to a recent literature review in The Lancet, bereaved individuals report diverse psychological reactions, with depression or anxiety frequently becoming clinically important. Bereavement is also associated with an excess risk of mortality due to many causes, including suicide, particularly in the early weeks and months after loss. ¹⁶

Bipolar disorder

Bipolar disorder is characterised by periods of mania (excessive excitement) or hypomania that may be followed with episodes of depression. ¹⁷ It is generally divided into two key types.

Bipolar I involves at least one manic episode during which time the individual has a heightened mood and a sense of being virtually indestructible. During manic episodes, self-esteem may be abnormally elevated and there may even be delusions of grandeur; the individual may be extremely talkative, have racing thoughts, and a reduced need for sleep. Sometimes speech becomes pressured (difficult to interrupt), thoughts become scrambled, disorganised or illogical, perceptions altered, and auditory hallucinations may occur.

The periods of mania can last for months and cause severe consequences, because the individual may engage in activities that are poorly thought out and sometimes quite dangerous. For example, the individual may make over commitments, rash personal decisions, spend recklessly, and engage in risky sexual behaviour, and/or the use of drugs or alcohol. Hypersexuality is often reported among manic individuals. Mania may or may not be followed by an episode of depression - which may at least partly be due to dealing with the consequences of their mania.

People with Bipolar II disorder experience hypomania (less severe and without psychotic features) followed by bouts of depression - often within the same week. Bipolar II is generally much less destructive to one's social or work life.

AIDS mania: There are several reports in the literature of people without prior or family history of bipolar disorder who have developed a similar manic syndrome in the end-stage of HIV infection, which may be due to opportunistic infections or the direct effect of HIV.

Schizophrenia

Schizophrenia is believed to be a thought disorder characterised by disorganised speech and behaviour (such as dressing inappropriately, or purposeless movements/catatonia), perceptual abnormalities, delusions, and hallucinations (referred to as positive or criteria A symptoms), sometimes accompanied with apathy, withdrawal from social interaction, and a loss of will (negative or criteria B symptoms). The individual may believe that external forces have taken control of their thoughts and actions, or that their thoughts are being broadcast.

While genetic, early neurodevelomental, early environment or psychological factors may play a role in the development of schizophrenia, it often appears to be catalysed by a stressful event, usually sometime between adolescence and young adulthood, after which time, it becomes a neuropathology. There is rarely a return to the premorbid state, though symptoms may be ameliorated and suffering reduced.

There can be grave consequences of developing schizophrenia or other severe psychoses in some settings where such behaviour is highly stigmatised and where people may even attribute the symptoms to witchcraft or possession by spirits.

Substance abuse disorders

A disorder related to the misuse or dependence on a substance such as a drug, alcohol or medications that alters one's senses. Importantly, many persons with a substance misuse disorder have a concurrent mental health disorder - and their substance misuse could be a misdirected attempt to self-medicate.

Substance abuse refers to recurrent use or indulgence of a substance despite the fact that it causes social, occupational, psychological or physical problems for oneself or harms others. For instance, substance abuse may be associated with a failure to fulfil work, school, or family responsibilities, driving while intoxicated or engaging in other dangerous activities while intoxicated, or getting in trouble with the law.

S ubstance dependence is physiologic dependence on a substance that occurs when compulsive and repetitive use result in tolerance to the effect of the drug and withdrawal symptoms when use is reduced or stopped. Eventually, the individual will sacrifice key assets (time, money, employment and relationships) to continue taking the substance.

Other disorders

Anxiety disorders include a large number of conditions characterised by abnormal or inappropriate feelings of worry or panic, with heart palpitations, sweating, tensed muscles, agitation, nervousness but without any immediate reason for such a reaction. Other anxiety disorders result in an entirely different emotional response, such as social phobias or agoraphobia.

Anxiety may manifest as an adjustment disorder after a negative life event, such as conflict, HIV diagnosis, or related negative events, such as rejection and stigma, or losing a loved one to AIDS.

Post-traumatic stress disorder (PTSD): PTSD is a form of anxiety disorder following a traumatic event that causes intense distress, recurring fears and/or helplessness in an individual. Symptoms may follow soon after the event or only manifest years later and may include re-experiencing the trauma through nightmares, obsessive thoughts, and flashbacks, avoidance of situations associated with the event; psychological or social withdrawal; irritability, jumpiness, or aggressiveness.

Sexual dysfunction is a very common problem in people with chronic ill health. It can also contribute to other mental health problems (e.g. depression) and have a significant impact on quality of life and feelings of self worth. These conditions might be especially common in people with HIV, because of the association of sex with their diagnosis, the fear of transmitting the virus to others, or the fear of rejection following disclosure of HIV. There may also be physiological reasons for sexual dysfunction that need to be considered in differential diagnosis.

Sleep disorders are common among people with HIV and may interact with other complications, exacerbating cognitive and memory problems, and potentially complicating adherence to treatment schedules. HIV-related sleep disorders may be characterised by a shorter total sleep time, a delayed time failing to sleep and reduced sleep efficiency (restless sleep with more time spent awake).

Personality disorders are enduring and inflexible patterns of behaviour that may cause personal or social difficulties. These are perhaps the most subjective of diagnoses listed here, and perhaps the most rooted in expectations that vary by culture (The DSM-IV lists 10 such disorders, the ICD-10 eight). Studies in industrialised societies report that many people with HIV have personality disorders, especially the DSM-IV's borderline personality disorder (BPD), which is characterised as having a low sense of self-worth, intense fear of abandonment that leads to clingy, or attention-seeking self-destructive behaviour (including impulsivity regarding sex and drugs) which in turn causes instability in relationships.

The pattern of behaviour may result from abuse, loss or some other psychosocial factor that established a very negative self-image during childhood, leading some critics to charge that BPD may simply be a reaction to PTSD. But since the diagnosis is much more likely to be made in women, it has been labelled as sexist. ¹⁸ Even though the personality traits and psychological risk factors linked with BPD are commonly found in resource-limited settings, it is not a diagnosis that is commonly reported in non-Western literature. ¹⁹ However, it is possible that people just "act out" in culturally specific ways. ²⁰

Do mental health disorders increase the risk for HIV infection?

In industrialised countries, such as the US, several studies suggest that people with severe mental illness have a dramatically higher HIV prevalence than the general population, with rates of HIV infection ranging from 3.1% to 22.9% (compared with an HIV prevalence of 0.3% to 0.4% in the general population in the US). 21, 22, 23, 24 A recent American study among the general psychiatric population at Duke Hospital (people with less severe problems) found that HIV infection was present in 1.2% of the psychiatric outpatients, approximately four times the HIV prevalence in the general adult population. ²⁵ Among the general psychiatric population, HIV prevalence was higher among people with substance abuse disorders (5%), personality disorders (3.1%), bipolar disorders (2.6%), and PTSD (2.1%). To explain these rates, many studies have looked at the effects of mental illness on behaviour and living circumstances.

For instance, one study of people presenting for voluntary HIV testing found they had a sevenfold increase in lifetime rates of mood disorders, such as MDD, compared to the general population. ²⁶ Other researchers have identified depression as a risk factor associated with unprotected sex, multiple sex partners, and contracting sexually transmitted diseases. 27, 28, 29 The situation is often compounded by alcohol and substance abuse, but in a survey of people attending a sexually transmitted disease clinic, HIV risk behaviours were still significantly higher in those with depression compared to non-depressed people even after adjustment for substance abuse. ³⁰ "Depression may increase the likelihood of engaging in these behaviours to mitigate distress, and depression can compromise motivation to change these behaviours," Hutton et al wrote.

Similarly other studies have found that other psychiatric disorders also increase vulnerability to HIV infection though people with different diagnoses may be more prone to engage in different kinds of high-risk behaviour. ³¹ People experiencing mania or hypomania may be more likely to engage in unsafe sexual and substance abuse behaviours. ³² A survey of psychiatric patients in New York found that people with excited symptoms (mania) were much more likely to have multiple sex partners, while exchanging sex for money or drugs was much more common among people with schizophrenia than among those with other diagnoses. ³³ Triesman et al noted that "patients with schizophrenia generally receive poor medical care, and are often involved in coercive sexual behaviours and substance use." ³⁴

Substance abuse also places people at increased risk for contracting HIV, both directly (in the case of injecting drug use), or because of increased sexual risk-taking behaviour associated with intoxication or addiction. Injecting drug use is the leading risk factor for HIV in many parts of the world. ³⁵ Another recent review found a strong association between HIV-infection risk and the use of alcohol and non-injecting drug use. ³⁶ When lives are so disrupted by substance dependence that people live on the streets or in unstable housing, exchanging sex for drugs or money may be more common. 37, 38

So there is little doubt that mental health disorders that impair judgment could increase risk-taking, and that people with mental illness may be less able to negotiate safe sexual encounters and be subject to coercion. Some people suffering from severe mental health problems may be unable to access or understand information about HIV/AIDS and thus protect themselves. Also, some people with severe depression or who have low self-esteem may not care whether they become infected, or may act in a way they perceive to be self-destructive. Finally, serious mental disorders may make it difficult for someone to find or keep employment and maintain steady relationships. They are more likely to experience periods of homelessness and thus may be coerced to engage in risky behaviour in order to survive.

But again, these data come from lower prevalence settings, where the HIV epidemic is primarily found among most-at-risk populations (men who have sex with men, sex workers and injecting drug users (IDUs)) who also have a greater burden of mental illness because of their marginalisation by society. The psychosocial factors associated with mental illness in other parts of the world are often quite different, as are the socio-demographics of the HIV pandemic (although it is important to remember that epidemics among most-at risk populations coexist alongside generalised epidemics).

Substance abuse disorders, especially alcohol abuse, in sub-Saharan Africa, have consistently been associated with a higher rate of sexually transmitted infections, greater numbers of concurrent sex partners, less condom use and exchanging sex for money and alcohol. 39, 40, 41, 42, 43 But there are fewer data on the burden of HIV in people with other mental illnesses in resource-limited settings, and what data are available do not consistently show a greatly increased risk of HIV.

In a 2003 study in Tamil Nadu India, the HIV prevalence among newly admitted psychiatric patients was found to be 1.03%. ⁴⁴ The authors concluded that this was not significantly higher than the prevalence for other hospital admissions of 0.7%, which also happened to be what, at the time, was believed to be the national HIV prevalence. However, since then, India has concluded that earlier estimates of HIV were about twice as high as they should have been and HIV prevalence is currently estimated to be around 0.34%.

A survey of sexual activity among psychiatric patients in southern India found less sexual risk taking than expected. ⁴⁵ "We found that only 5% of the patients reported high-risk sexual behaviour in the past years," wrote Chandra et al; however, they noted that, "in India, it is more common than it is in the West for adults to continue to live with their families, which may restrict opportunities for sexual activity."

This might be true of people with mental illness in a number of non-industrial societies. ⁴⁶ Of note, a survey of outpatients with schizophrenia in Nigeria found that they were significantly less likely to be sexually active than a matched patient group (people with diabetes). ⁴⁷ However, they had more misconceptions about HIV/AIDS and were also more likely to engage in high-risk behaviours when they did have sex. That study did not assess the HIV burden amongst the two groups however.

A subsequent study in India, which looked at the prevalence of several sexually transmitted infections in people seeking treatment for a mental disorder in India, suggested that there was in fact some increase in risk. Out of 1,639 subjects, 948 were stable enough to consent to be interviewed and screened. The study found a prevalence of 1.7% for HIV, 3% for hepatitis B, 3.1% for syphilis, and 10% for chlamydia - rates that appear to be higher than those in the general Indian population.

There is an appalling lack of data in sub-Saharan Africa. What data there are come from southern Africa and report an HIV prevalence among psychiatric patients that is not dissimilar to that among the general population - though given how high the HIV prevalence is in southern Africa, that is of little comfort.

A study from Zimbabwe in 1996 screened 143 inpatients admitted to Harare Central Hospital's Psychiatric Unit and found an HIV prevalence of 23.8%. ⁴⁸ More recently, Dr Pamela Collins of Columbia University conducted a study at a public psychiatric institution in KwaZulu Natal, South Africa, among 151 patients who were psychiatrically stable and able to give informed consent. 49 Forty people (26.5%) were HIV-positive; as in the general population, women were more likely to be infected than men (OR 2.74; 95% CI=1.25-6.04; p=0.012).

Because of testing consent issues, these surveys may be missing a greater burden of HIV among people with severe mental illness. ⁵⁰ But it is possible that in settings where HIV is hyperendemic and where being involved in multiple concurrent sexual partnerships is normative behaviour in the general population (and is, in fact, largely what is driving the epidemic), mental illness may not so greatly increase risk.

Again, there are fewer data in African settings and some of it seems conflicting. For instance, a study in a Cape Town township found that people with depression, reported alcohol abuse, and PTSD were more likely to report experiences of forced sex [adjusted odds ratio (AOR) 2.53; 95% confidence intervals (CI) 1.60-4.02], transactional sex (AOR 2.88; 95% CI 1.29-6.48) but also increased condom use (AOR 2.07; 95% CI 1.32-3.25). ⁵¹ The authors noted that because of the cross-sectional nature of the survey, no temporal associations could be made (in other words, the causal relationship is unclear -the PTSD may well have been the consequence of the forced sex).

Regardless, the two African HIV prevalence surveys noted above demonstrate that there is a clear need for HIV services among vulnerable people with mental illness. Collins et al wrote "These results underscore the importance of integrated mental health and HIV care in institutional and outpatient mental health settings and affirm the need for detailed HIV risk assessment as a routine part of psychiatric care. Correspondingly, HIV care and treatment programs should be made available to people with psychiatric symptoms." ⁵²

The burden of mental illness in resource-limited settings among people with or affected by HIV

On top of the baseline of pre-existing mental illness among people with HIV can be added mental health complications that may emerge once people learn their diagnosis, and try to deal with HIV-related ill health, stigma, discrimination, rejection or bereavement, as well as financial, employment and relationship problems. ⁵³

According to studies from North America and Europe, this results in an enormous burden of mental health issues in people with HIV. One survey of HIV-doctors and their patients even suggested that 70% of people with HIV experience some mental health problem. A large meta-analysis confirmed that people with HIV were almost twice as likely to suffer from major depressive disorder as matched people in the general population. ⁵⁴

And a WHO report last year stated "that the prevalence of mental illnesses in HIV-infected individuals is substantially higher than in the general population," though it also noted that "HIV tends to be concentrated in highly vulnerable, marginalised and stigmatised populations" who have "have higher levels of mental health disorders than the general population."

But once again, there are very limited data from resource-limited settings where HIV is more common in the general population, where many people, HIV-infected or not, may face very trying life circumstances, but where coping mechanisms and social capital are also quite different. The data that do exist, if taken at face value, would mean the burden of mental illnesses in people with HIV varies dramatically across different parts of the world and populations. Some of the heterogeneity in study findings stem from "the variation in mental health instruments, sampling, study design, and timing of the assessment in relation to receiving the HIV diagnosis most likely influenced the prevalence of mental illness reported," according to a review by Collins et al. ⁵⁵ In fact, very few of the studies from resource-limited settings assess mental health in the same way.

However, in one of the largest studies, conducted over 15 years ago, investigators used a screening tool that had been validated for cross-cultural use in five cities - São Paulo, Brazil, Bangkok, Thailand, Munich Germany, Kinshasa, Democratic Republic of Congo (DRC), and Nairobi, Kenya - to compare rates of mental illness among people with HIV and matched HIV-negative controls. ⁵⁶ Overall, only about 6% of the participants had depression, and while symptomatic people with HIV had significantly higher depression scores than the HIV-negative controls, this wasn't consistently the case for those without symptoms. The highest levels of mental health diagnoses (~20%) were recorded amongst symptomatic HIV-positive MSM in Sao Paolo, Brazil and IDUs in Bangkok - but such illnesses were relatively uncommon in people with HIV from Kinshasa and Nairobi, even among symptomatic people.

The lower overall incidence of mental illness in the African sites of this study is curious, but it is not the only time such an observation has been made: the World Health Organization (WHO) World Mental Health (WMH) Survey Initiative looked at one African country - Nigeria - and found that only 4.7% had had a DSM-IV disorder in the past 12 months (with a 12.1% lifetime rate). ⁵⁷

Somewhat higher rates have recently been found in a large study in Zambia which recorded "mental distress" in 15.4% of surveyed women and 12.4% of surveyed men. ⁵⁸ Of note, the prevalence of HIV was 13.5% and 18.2% for the rural and urban population in the study, but most of the survey participants (86.4%) did not know their own HIV status. Even so, the study's authors believed that much of the mental distress that was found may have been due to HIV- both directly and indirectly through its effect on health - since factors such as self-rated health, self-perceived HIV risk and worry of being HIV-infected were closely related to mental distress.

Poor mental health seems much more common in South Africa where, after HIV, neuropsychiatric disorders comprise the second largest component of the national burden of disease. ⁵⁹ In a household survey involving 4351 South African adults (the South African Stress and Health (SASH) survey), the lifetime prevalence of DSM-IV disorders (using the World Health Organization Composite International Diagnostic Interview (CIDI) was 30.3% for any psychiatric disorder, including 15.8% for anxiety disorders, 9.8% for mood disorders (including MDD), 13.4% for substance use disorders. ⁶⁰ These rates are lower than in some Western countries but higher than in most of the other countries in the World Mental Health Survey.

Stein et al suggest the higher rates of mental health problems could be due to South Africa's recent history of racial discrimination, political violence, and ongoing socio-economic disparities, high rates of gender inequalityand criminal violence. But another factor could be the enormous burden of HIV/AIDS and AIDS-related mortality in the country. Many survivors of the concentrated HIV epidemics in the West are deeply traumatised by the impact of the AIDS epidemic on their communities, and emerging data are suggesting this may also be the case among deeply affected communities in southern Africa.

Earlier this year, a further analysis of the SASH survey concluded that mental health diagnoses were significantly more common in people who knew someone who had died of AIDS - and researchers calculated that up to 15% of 12-month DSM-IV disorders in the South African adult population could be due to the impact of AIDS-related mortality. ⁶¹ Of course, many of those who knew people who have died of AIDS may have also been dealing with their own HIV diagnosis.

For instance, in one study, researchers from the University of the Witwatersrand in Johannesburg found depression in about 56% of the people with HIV (and this was unrelated to subjects' immune status). ⁶² In another study, 56% of people with HIV had at least one psychiatric disorder at baseline, and 48% of patients had at least one psychiatric disorder at 6 months. ⁶³ Depression and PTSD were the most prevalent disorders both at baseline (34.9% and 14.8%) and follow-up (26% and 20%), respectively.

In contrast, a study presented at this year's South African AIDS Conference (SAAC), used the same tool (the MINI International Neuropsychiatric Interview) in over 600 people with HIV in the Free State Province and only found 15% with anxiety and 9% with depression. ⁶⁴

Another study presented at SAAC screened for common mental disorders in 302 subjects attending the Nthabiseng HIV Clinic at Chris Hani Baragwanath Hospital and three HIV Wellness clinics (one in Soweto, one at an informal settlement south of Johannesburg, and one at a rural hospital in Limpopo Province). ⁶⁵ 31% of the participants had a current mental disorder (40% had a disorder at some point in their life). Almost 21% had a current depressive and/or anxiety disorder, 7.6% had a substance use disorder. Notably 60% of those with a lifetime depressive disorder had their first onset after their HIV diagnosis.

A systematic review of 23 studies on the mental health of people with HIV was recently published in the African Journal of AIDS Research by René Brandt of the University of Cape Town. She concluded that, "the majority of the studies reviewed reported that about half of HIV-infected adults sampled had some form of psychiatric disorder," while depression was the most common clinical disorder (over 20% in most studies). ⁶⁶

Given Dr Dlodlo's comments earlier in this HATIP, it's not surprising that some of the most disturbing findings came from Zimbabwe. These came from a cross-sectional study using a number of assessment tools on a convenience sample of 200 subjects recruited in Epworth, a township outside of Harare, Zimbabwe, that had a very high point-prevalence of HIV - 59.3%. ⁶⁷ 71.3% of the people with HIV were suffering from mental health complications compared to 44.3% of those who were HIV-negative (OR=3.12, 95% CI=1.64-5.95, P=0.0002). The most common psychiatric symptoms were "emotional withdrawal, depressed mood, suspiciousness, apparent sadness, reduced sleep and suicidal thoughts (especially among women)."

Another study that found a very high rate of mental disorders comes from Uganda, where researchers enrolled patients attending a TASO (The AIDS Service Organisation) clinic (every fifth consenting person with HIV attending the clinic). ⁶⁸ Notably out of the 46 total subjects, 31 were also unemployed. Participants were interviewed using the MINI tool - and 82.6% were found to have at least one psychiatric disorder. 54.3% had MDD, 17.4% bipolar affective disorder, 17.4% psychoses (non-affective) and 32.6% a panic disorder. 23 patients (60.5%) had multiple diagnoses. The disorders were generally severe -13% had current suicidal thoughts. "The need for psychiatric treatment is high among those attending the clinic, but none was receiving any form of psychiatric treatment or care at the time of the survey," the authors wrote.

It is difficult to reconcile the high rates of mental illness in this study with the lower rates found in so many other African studies, but the differences could be explained by different economic, psychosocial, socio-demographic and health-related risk factors that make poor mental outcomes more likely. Brandt looked at such factors across the 23 African studies in people with HIV and concluded: "Those experiencing less [mental health] problems were less likely to be poor and more likely to be employed, educated and receiving antiretroviral treatment (ART)... Evidence has also suggested that HIV-infected women may be at greater risk than HIV-infected men for poor mental health, at least where depression is concerned, while levels of alcohol and substance use are higher among men. Poor health, receiving poor-quality health services, and a lack of material and emotional support from one's family and friends were also associated with greater psychiatric morbidity among PLHIV," she wrote.

A glance at some recent studies from Tanzania supports the conclusion that some psychosocial risk factors increase mental health morbidity in some people with HIV. One screened 220 people with HIV from a rural Tanzanian clinic for mental health disorders (as defined by ICD-10) and identified depression or mixed anxiety and depression in 15.5% of subjects (2.7% had severe depression) with 4.5% suffering from other anxiety disorders (phobias and panic disorders). ⁶⁹ Perhaps living an agrarian life (where people may receive more family and community support) reduces poor mental health outcomes as opposed to living in an urban or periurban setting because these findings were at the lower end of the range of what was found in other studies from Tanzania.

For instance, in urban Tanzanian settings, depression was found in 45% of HIV-positive mothers one year or more postpartum (perhaps not surprising given the stresses related to motherhood) ⁷⁰ and in 21% of outpatients on ART. ⁷¹ However, the authors of the rural study noted that there is also a possibility that this one centre was unusually supportive of its clients (it provided free food, transport and a social worker). One of the authors, Dr Katie Marwick of the University of Edinburgh, told HATIP that they also assessed predictors of mental illness, which are not included in the final paper because of wide confidence intervals. "It is still interesting to note that the pattern of risk factors replicates other published findings," she said.

Another factor identified by several studies is internalised stigma felt by some people with HIV. ⁷² A US study found that internalised stigma contributed significantly to levels of depression, anxiety, and hopelessness even after controlling for the effects of behavioural variables, health status, and demographic characteristics - and may help explain the differences seen in different studies. ⁷³ Subsequently, there were similar findings in a study in Cape Town, which found that internalised stigma was a significant predictor of depression, in an analysis that also included demographic characteristics, health and treatment status, social support, and substance use. ⁷⁴

Stigma was also a major factor associated with depression in Peru, where over two-thirds of Peruvian women living with HIV and poverty were reported to be suffering from depression.

More recently, at the South African AIDS conference earlier this year, a poster presentation described a study involving over a thousand participants in both Cape Town and Swaziland, and 239 participants in Atlanta, Georgia, reported that despite obvious cultural differences, internalised stigma was positively correlated with depression scores in all three countries, with higher internalised stigma scores associated with more severe depression. ⁷⁵ Subjects who reported greater social support were also less likely to have internalised stigma.

Access to HIV treatment and care, especially ART, could be another factor affecting the extent to which an HIV diagnosis increases the risk of mental illness (and something which has changed dramatically in resource-limited settings in the last several years). However, while ART may help people cope with having HIV, a study presented at this year's HIV Implementers' Meeting suggests that it is unlikely to affect mental health problems, such as substance use disorders, that were present before someone's HIV diagnosis - and there may be other unexpected consequences of treatment as well.

Case study: mental health, substance misuse and HIV treatment in Vietnam

"My nephew has only been on ART for a year. When he had just started the treatment, his CD4 counted was only 3 cells. After one year, he gained seven kilograms and was quite healthy. Then he fell back onto drugs. Everyone in my family advised him but he did not listen. He skipped dosages from time to time and completely stopped the treatment a few months ago. He had from three to four dosages of drugs [heroin] a day. He died recently." A comment by a male living with HIV in Ho Chi Minh City, Vietnam

"While physical health improves across the board for PLHIV on ART, we find there are clearly issues related to livelihood, self-esteem, sadness and drug relapse, which are important factors influencing quality of life and adherence in our clients," Dr Kimberly Green of Family Health International, said during a session on Mental Health at this year's HIV Implementers' Meeting in Windhoek, Namibia. ⁷⁶

She was describing the findings of two studies: one, an observational cohort study initiated in 2005 to measure clinical, psychosocial and behavioural outcomes of ART in a population of 247 people with HIV attending two outpatient clinics in Ho Chi Minh City; the second, a subsequent quality of life study.

Although the two clinics are linked with a number of interventions to support people with HIV, such as community and home-based care, support groups as well as support for children affected by HIV, there was very minimal mental health support provided. According to Dr Green, this is fairly typical of Vietnam, where most of the mental health services are provided at the provincial or tertiary level hospitals, and almost all on an inpatient basis.

When Dr Green and her colleagues observed poor or decreasing quality of life responses from their patients, despite excellent clinical responses, they developed a qualitative study that was embedded into the cohort study, focused on five areas:

Client perceptions on quality of life resulting from ART

Client adherence to ART/factors affecting adherence

Client perception of clinic-based and community and home-based care (CHBC) services provided by staff and referral services

How introduction of ART may have changed stigma and discrimination in different settings

Changes in sexual risk and drug-using behavior

The study randomly selected participants from the observational cohort (including their families) as well as clinic clients who had not been study participants, to tease out any differences between those who enrolled in ART and were part of the study from the very opening of the clinic versus those who had started ART later. Methods included nine focus groups and 42 in-depth interviews with 96 people.

They found that most participants scored their quality of life as a '5' on a ten-point scale - in other words, mediocre. What was good about their quality of life was their improved physical well-being, but a number of social and emotional issues were dragging the quality of life down. These included:

Lack of employment

Feeling 'lost' and that life was without meaning

Lack of self-confidence

Feeling sad, depressed

Drug relapse

Lack of support from family members

Anxiety about their health and future

"Lack of employment was seen as a major problem and one which contributed to lack of self-confidence, lack of pride and lack of independence, and linked with this was a feeling which was described as "feeling lost", feeling that life had no purpose," said Dr Green. Ironically, becoming ill with HIV had initially given peoples' lives some focus: getting better and accessing ART. But now that their lives had stabilised, many felt a void, which many said could be filled if they could just find employment. This would also improve their ability to get their families support, which many felt had decreased since going onto ART.

"People living with HIV who participated in the study said that their families were very supportive when they were ill and when they were first enrolled on ART, as adherence supporters. But once they felt better, they were expected to contribute to the income of the household -particularly since a lot of the other family members had allocated their own resources for their healthcare. So with that expectation on people living with HIV in the study to provide more support to the family, they felt like family support had been withdrawn," said Dr Green.

Ironically, even though ART had improved their health, many participants said that they felt closer to death because their immune systems were no longer able to function without medicines.

'You see, I even felt sadder when taking ARV... By that time I understood that meant I was very weak already. For me, when I still felt well, that meant my CD4 count was above 200. I was living positively, no sorrows... until I was put on ART... I knew that I was... almost gone, ' said one.

The ongoing emotional distress made it more difficult for clients who were former substance users to avoid relapse - and failure to adhere to treatment. Notably, in the quantitative study, there were very high rates of documented adherence (95% or more reported 95% or greater adherence) - this was measured through individual reports and clinic records. However, participants in the qualitative study and their healthcare providers estimated that excellent adherence rates would be no more than 70%. They identified drug and alcohol use as the major contributors to low adherence rates; but sadness, depression and lack of work and social support were also key factors.

'Among 100 clients on ART here, I can say that from 20 to 30% are using heroin, ' said one participant. According to Dr Green, "a number of the people who participated in the research, estimated the relapse rates to be around that percent. But there were a few who thought it was even higher."

Recommendations from Dr Green's study come later in the article.

Moving forward with a shaky evidence base

While no one could argue that there is a need to implement mental health interventions for people with HIV and visa versa, both Collins' and Brandt's reviews characterise the available evidence base as somewhat less than robust. High quality research is needed to determine the true scale of the mental health challenges that ART and HIV care programmes are facing.

Collins et al wrote that, their "review demonstrates the need for methodologically sound studies of mental health throughout the course of HIV and interventions that employ identified variables (e.g. coping, family support) for efficacy in reducing symptoms of mental illness."

"Mental health services are needed for all those faced with poverty and exposure to high HIV prevalence. However, the particular risks and experiences associated with being HIV-positive should be the subject of empirical research aimed at driving policy and practice," wrote Dr Brandt. She added that, "research on predictors of mental health outcomes and on factors associated with adherence to ART, which can be targeted in interventions (for example, coping strategies) should also be prioritised."

The impact of mental health on HIV-related outcomes

Regardless of how great the burden of mental disorders in the local population, when a person with HIV is suffering from poor mental health the data from both resource rich and constrained settings consistently show that it can delay his or her health-seeking behaviour (in fact, decreased health-seeking behaviour may result in the true burden of mental illness in people with HIV being under-recognised), may decrease adherence to treatment, and increase the likelihood of dropping out of HIV risk reduction programmes. 77, 78, 79, 80, 81

For instance, a recent study from Ethiopia, reported that people without depression were twice as likely to be adherent as those who were depressed (OR, 2.13, 95%CI, 1.18, 3.81). ⁸² However, the authors noted that patients who reported better social support also had better adherence, and as other studies have pointed out, depression and a lack of social support are closely linked. Also, in addition to adherence to medication schedules, Dr Joska believes that HIV programmes need to consider that a fair amount of their losses-to-follow-up are likely due to poor mental health and substance abuse. ⁸³

But mental health disorders should never become an excuse to withhold ART because studies have shown that treatment of depression and other mental health conditions can achieve good adherence to antiretroviral regimens and therapeutic outcomes. 84, 85 In fact, a recent US study found that people with psychiatric disorders were significantly less likely to discontinue ART - but it is important to note that this was also linked to the number of mental health visits that these patients had, which may have been opportunities to reinforce the need for good adherence. ⁸⁶

But to treat or provide therapy for mental health disorders, programmes must first detect them.

Improving mental health services for people with HIV

At a routine postnatal visit, an assessment by Daya's primary care provider picked up that she had a problem and the nurse investigated further. She referred Daya to a community counsellor, who enrolled her into a community group therapy programme for new mothers.

During one group therapy session, Daya heard that many other women had had similar troubles. She finally opened up about everything that had happened to her over the past year. She told the group about her HIV status, how her husband had beaten and then left her, and the difficulties she was having with Chipo.
She told them she was afraid that Chipo might turn out to be HIV-positive even though they took medications to prevent this in the PMTCT programme. She also told them she was afraid of dying from AIDS, and how occasionally thoughts of killing herself and her baby had crossed her mind.
She kept going to group therapy and on her primary care nurse's recommendation, also started taking an antidepressant medication. In just a month, the clouds began lifting. She successfully weaned Chipo onto replacement feeding and no longer felt suicidal. In fact, she actually started smiling again. ⁸⁷

The case for expanding and decentralising mental health services

Daya is extremely fortunate to have been attended to by a health worker who actually took the time to assess her wellbeing at the clinic visit and then to initiate appropriate care and treatment (in this case, both antidepressant medication and community-based services). Many people aren't so lucky because of the global failure to invest in mental health services.

"The public mental health budget in many countries is mainly spent on maintaining institutional care, with few or no resources being made available for more effective services in the community," according to the 2001 World Health Report. ⁸⁸ And these institutions have an appalling track record.

"Psychiatric hospitals have a history of serious human rights violations, poor clinical outcomes and inadequate rehabilitation programmes. They are also costly and consume a disproportionate proportion of mental health expenditures," according to the WHO/WONCA Report.

Furthermore, it seems highly unlikely that someone with depression, or suffering from bereavement would ever make a long journey looking for such an institution to find help. Even people with the most severe disorders are poorly served by this approach to care. ⁸⁹ As a result, people like Daya usually suffer in isolation.

The only way to address this treatment gap is to bring these services closer to where people may actually access them. In fact, WHO has been recommending that psychiatric hospitals be closed and replaced by services in general hospitals, community mental health services and services integrated into primary care.

"Integrating mental health services into primary care is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need," according to the WHO/WONCA report. The Lancet Global Mental Health Group argued that a basic, evidence-based package of services for core mental disorders could easily be scaled up. ⁹⁰ They estimated that the amount needed to provide services on the necessary scale for three mental disorders (schizophrenia, depression, bipolar affective disorder) and one risk factor (hazardous alcohol use) would be US$2 per person per year in low-income countries and $3-4 in lower middle-income countries, "which is modest compared with the requirements for scaling-up of services for other major contributors to the global burden of disease." Some suggested that the first place to start would be to integrate mental health care into HIV services. ⁹¹

There might be some logic to this according to Dr Anthony Harries, of the International Union Against Tuberculosis and Lung Disease (formerly of the Ministry of Health in Malawi).

"Mental health tends to be chronic and we have been arguing for a couple of years that HIV care is similar to care for other chronic diseases such as diabetes, hypertension and also mental health. I don't see why we cannot have chronic care clinics that look after communicable and non-communicable diseases at the same time," he told HATIP. In Malawi, Dr Harries and others adopted key elements of the DOTS model to roll-out HIV services extremely rapidly; and he was recently the lead author of a PLoS Medicine paper recommending that the model be used for other chronic non-communicable diseases (NCDs). ⁹²

"How are NCDs currently managed in the routine health care settings of African countries? In brief, badly," wrote Dr Harries and his colleagues. "Some of us know from personal experience of running routine diabetes and hypertension clinics in African hospitals that there are no formalised systems of recording how many patients have been diagnosed and started on therapy, how many are retained on therapy, or what proportion have died or developed complications. In summary, unstructured and unmonitored clinical care and little information about morbidity or mortality from NCDs are mostly the norm in sub-Saharan Africa. How do we begin to rectify this unsatisfactory situation? A possible solution arises out of the existing "DOTS" framework for control of TB."

In the meantime, however, there is a danger that provision of mental health services could become just another task that is loaded onto overburdened health workers - but a particularly challenging one because most health workers have only limited training in mental health. And while training of primary health-care workers to take on more of these tasks may achieve some short-term successes, another series of papers in the Lancet (September 2008) on the Rebirth and Revision of the Alma Ata Declaration pointed out that studies have shown that these benefits diminish over time without sustained and adequate support. The series noted that back in 1978, the Alma Ata Declaration called for the expansion of comprehensive health service delivery at the primary care level, but in the years since - and in a climate where nurses are being tasked with more and more to do - there has been a shift towards recognising the strengths of integrated systems (mixed vertical programmes and primary care systems) - which can offer both greater reach and high quality support. ⁹³

"Experience in low-income and middle-income countries indicates that to be fully effective and efficient, primary care tasks must be limited and feasible. Primary mental healthcare (as with primary health care for other chronic diseases) must be complemented by additional levels of service, including components of secondary care to which primary health workers can turn for referrals, support, and supervision," wrote Beaglehole et al in another paper in that Lancet series. ⁹⁴

This sort of multi-tiered expansion of mental health services is exactly what Dr John Joska seems to be developing in Cape Town. Initially his programme was funded to provide tertiary level care to people with HIV who had severe mental illness and complex neuropsychiatric disorders, but Dr Joska soon concluded that this group was already fairly well catered for by the existing psychiatric services.

"What was really needed was input into ambulant ART services," he told HATIP. "Our first step was to provide adequate referral support across the metro of Cape Town. To this end, I have appointed a psychiatrist to each side. These people manage referral clinics at the busy regional/district hospitals and some referral centres. My next step was to introduce the notion of screening for common mental disorders including substance abuse at primary care." At present, this consists of a screening project at two pilot sites where a project manager and a nurse are screening and providing services.

"I have come to believe that clinics need a dedicated HIV mental health nurse present, at least for 1-2 days of the week. I am trying to find a way to convince the Province that if they want to retain people in care, they must do this. In parallel, we have begun to provide training in mental disorders to counsellors entering the service."

There are some steps HIV programmes can take to detect and better manage mental disorders among their clients, but it is important to stress that it will take a multidisciplinary/team-based approach to tackle this issue. In regions such as the Western Cape, which is much better resourced than many other settings, it may be beneficial to add mental health specialists to the team. In other settings, HIV programmes will have to collaborate with other service providers.

"We recommend that, first, resources and time be dedicated to establishing and strengthening relationships to existing mental health services and HIV care programmes," Collins et al wrote. "This can be achieved as donors and program directors recognize the importance of allocating funds for mental health services in HIV care (including procurement of psychopharmacological medications) and stipulate mental health integration."

Screening for mental health disorders

Even so, given the prevalence of distress, depression, substance misuse and other disorders among people with HIV, many experts are arguing that HIV care providers should be routinely screening for these issues. Of course, some of this is already occurring in post-HIV test counselling, and ART readiness assessments. But Dr Joska doesn't think this goes far enough.

"I feel detection [of mental health problems] is below par, and that ongoing training, and the use of a tool would improve this," Dr Joska told HATIP - but he said that he is conducting a study on the use of such a tool to strengthen his case.

Although there are an abundance of mental health screening tools mentioned in the literature, only a handful have been adapted for use in busy clinic settings. Last year, Dr Vikram Patel of the London School of Hygiene and Tropical Medicine and colleagues ran a study comparing five tests under field conditions in almost 600 subjects attending five primary health clinics in India. ⁹⁵ The five instruments were the General Health Questionnaire (GHQ, 12 questions or items); ⁹⁶ the Primary Health Questionnaire (PHQ, nine items); the Kessler Psychological Distress Scale (K10, 10 items) ⁹⁷ and the shorter 6-item K6; and the Self-Reporting Questionnaire (SRQ, 20 items). ⁹⁸ Every participant was then interviewed with a much more involved structured lay diagnostic interview, the Revised Clinical Interview Schedule (CIS-R). ⁹⁹ The researchers concluded that the GHQ and SRQ showed the best results but the tests had moderate to high degrees of correlation with one another.

The Zambian study mentioned earlier in the issue adapted a 10-item version of the SRQ to measure mental distress in Zambia, by adding weights to the 10 indicator questions, based on the adapted criterion for the DSM-IV classification for depression (with a cut off point of 7) (see box). 100, 101

SRQ-10 diagnostic symptoms and weights

However, this tool is primarily focused on depression. In a paper in the South African Journal of Psychiatry, Dr Joska and colleagues noted that there don't seem to be many tools that are tailored to the range of specific problems encountered in ART clinic populations. They could only find one, the Substance Abuse and Mental Illness Symptoms Screener (SAMISS), which has been validated for use in people living with HIV in the US.

The SAMISS (see below) includes sixteen screening questions for alcohol and substance abuse, major depression, panic disorder and PTSD, as well as adjustment disorders. We should note however, that some of the questions regarding substance abuse may be specific to the US - for example, it would label anyone who has a glass of wine or a beer with dinner each night as having a substance abuse problem. Other items could score differently than expected in a resource-limited setting as well. For instance, in her book HIV/AIDS Care and Counselling, Dr Alta Van Dyk notes that there are "cultural differences in the expression of depression - especially when these concern the duration of mourning after the loss of a significant other." ¹⁰² Nevertheless, in the US at least, a validation study by Pence et al concluded that the SAMISS was highly sensitive and had moderate specificity for both substance abuse and mental illness; and "due to its brevity," the researchers wrote "the SAMISS can be feasibly integrated into routine care in busy clinical settings." ¹⁰³

Of course, busy is relative, and it may be hard to imagine a nurse who doesn't bother to ask a patient about cough or fever (to screen for TB) using a sixteen-question checklist on mental health. It might be easier to include one or two questions about mood at each clinic visit -to flag potential problems and in order to understand whether a patient is suffering. As an initial screen, the Columbia Clinical Manual recommends using two basic questions such as 'during the past month, have you felt like you were losing interest or pleasure in doing things? Or have you felt down, depressed or helpless?' If there is a yes response to either of these questions further investigation is warranted. ¹⁰⁴

Notably, many palliative care assessment tools also include questions about psychiatric symptoms, such as the Edmonton Symptom Assessment Scale (ESAS) ¹⁰⁵ which was developed for use in cancer patients to rate the severity of common symptoms including anxiety and depression. Making at least some inquiry about the emotional and mental health of a patient could make the clinic visit more cordial - and perhaps make a follow-up visit more likely. And when a sign of distress is detected, a locally adapted version of the SAMISS might be useful for further investigation by a trained nurse or counsellor to assess the severity of the problem. However, people who are only 'mildly distressed' may also need psychosocial support to help prevent a more serious problem developing.

Dr Joska et al suggested that the SAMISS should be administered along with the International HIV Dementia Scale (IHDS) in any person who is just about to start ART, who has failed ART, or has been on ART for a couple of years.

The Substance Abuse and Mental Illness Symptoms Screener (SAMISS)
Substance abuse:
Respondent screens positive if sum of responses to questions 1-3 is ≥5, response to question 4 or 5 is ≥3, or response to question 6 or 7 is ≥1.

1. How often do you have a drink containing alcohol?

(0) Never (1) Monthly or less (2) 2-4 times/mo (3) 2-3 times/wk (4) ≥4 times/wk

2. How many drinks do you have on a typical day when you are drinking?

(0) None (1) 1 or 2 (2) 3 or 4 (3) 5 or 6 (4) 7-9 (5) ≥10

3. How often do you have ≥4 drinks on 1 occasion?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

4. In the past year, how often did you use non-prescription drugs to get high or to change the way you feel?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

5. In the past year, how often did you use drugs prescribed to you or to someone else to get high or change the way you feel?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

6. In the past year, how often did you drink or use drugs more than you meant to?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily

7. How often did you feel you wanted or needed to cut down on your drinking or drug use in the past year, and were not able to?

(0) Never (1) Less than monthly (2) Monthly (3) Weekly (4) Daily or almost daily
Mental illness:
Respondent screens positive if response to any question is ''Yes.''

8. In the past year, when not high or intoxicated, did you ever feel extremely energetic or irritable and more talkative than usual?

9. In the past year, were you ever on medication or antidepressants for depression or nerve problems?

10. In the past year, was there ever a time when you felt sad, blue, or depressed for ≥2 weeks in a row?

11. In the past year, was there ever a time lasting ≥2 weeks when you lost interest in most things like hobbies, work, or activities that usually give you pleasure?

12. In the past year, did you ever have a period lasting ≥1 month when most of the time you felt worried and anxious?

13. In the past year, did you have a spell or an attack when all of a sudden you felt frightened, anxious, or very uneasy when most people would not be afraid or anxious?

14. In the past year, did you ever have a spell or an attack when for no reason your heart suddenly started to race, you felt faint, or you couldn't catch your breath? (If respondent volunteers, ''Only when having a heart attack or due to physical causes,'' mark ''No.'')

15. During your lifetime, as a child or adult, have you experienced or witnessed traumatic event(s) that involved harm to yourself or to others? (If yes: In the past year, have you been troubled by flashbacks, nightmares, or thoughts of the trauma?)

16. In the past 3 months, have you experienced any event(s) or received information that was so upsetting it affected how you cope with everyday life?
Sources
Whetten K et al. Substance abuse and symptoms of mental illness among HIV-positive persons in the Southeast. South Med J. 98:9-14, 2005.

Whetten K et al. A brief mental health and substance abuse screener for persons with HIV. AIDS Patient Care STDS. 19: 89-99, 2005.

Pence BW et al. Validation of a brief screening instrument for substance abuse and mental illness in HIV-positive patients. J Acquir Immune Defic Syndr 40(4): 434-44, 2005.

Counselling and listening skills for health care workers

Simply having a tool is not enough. In addition to learning how to administer a tool, healthcare workers must be taught some basic counselling and listening skills in order to effectively administer a psychological assessment.

Regardless of what tool is used, the WHO/WONCA report stress that "health workers must ensure the confidential nature of consultations, and must refrain from appearing judgemental to patients." It also suggests including some more "open-ended questions to allow patients to tell their stories and discuss their concerns more freely."

Part of the challenge may actually be getting someone to sit through and participate in the assessment. Again, mental illness is highly stigmatised, perhaps most so by men. For instance, in the study in Zambia, "whereas refusal to participate was low, the non-participation due to absence was relatively high among men," wrote Chipimo and Fylkesnes.

Again, Dr Van Dyk stressed very striking differences in cultural communication that may need to be considered in a counselling or interview session:

Make sure that the way you orientate yourself to be with your client (attending) does not affront instead of reassuring your client. Read your client's body language and be guided by it.

Familiarise yourself with traditional forms of greeting, and make sure you can pronounce and spell the client's name correctly. Don't make judgments based on stereotypes such as the client's hairstyle or dress.

Bear in mind that people from different cultures may have different attitudes to matters such as personal communication distance, punctuality and time schedules.

It may be a problem if you are much younger than your client, or of the opposite sex. In many cultures elderly people customarily don't discuss their problems with younger people because 'they are children'. Discuss this potential problem with your client.

Respect the client's customs and ways of communicating. These may include making or avoiding of eye contact, who should sit, stand or walk first, how a man should act towards a woman and a woman towards a man, and how adults and children should behave towards one another.

Be aware that direct eye contact is not an admired form of behavior in all cultures. Many cultures regard it as rude, a challenge, or even as confrontational. In some cultures it would be regarded as ill-mannered if a young person were to look directly at an older person. Let the client be your guide - observe him or her and be sensitive to what is comfortable for him or her.

Many counsellors have the habit of touching their clients as a way of showing empathy. But touching may not be appropriate in all cultures. It could be seen as degrading (you touch a child out of sympathy, not an adult) or, if the touching involves a person of the opposite sex, it may be seen as an expression of sexual attention.

Dr Joska stressed that his programme matches the nurses to the patients' culture and language.

"I have tried to employ Xhosa speaking staff where possible. Nurses in our programme must be from the culture of the patients," he told HATIP.

Diagnoses

It should be remembered that the SAMISS and the IHDS are only screening tools, and highly sensitive ones at that.

"Cases detected by lay counsellors or nurses should then be referred to a mental health nurse for more detailed assessment," Joska et al wrote. This would involve the use of a more structured diagnostic tool, such as the MINI neuropsychiatric interview. ¹⁰⁶ "True cases may be managed on site by community mental health services, or referred to secondary support clinics if needed," they wrote.

A trained clinician should be able to make some diagnoses, such as for major depressive disorder. According to the DSM-IV-TR, this diagnosis can be made in the presence of five or more symptoms, including depressed mood and a loss of interest or enjoyment in previously enjoyed activities, for two or more weeks. The other key symptoms may include psychomotor agitation/ retardation, loss of concentration, fatigue, sleep disturbances, appetite or weight disturbances, suicidal ideation, and feelings of guilt or worthlessness. The presence of fewer symptoms could indicate an adjustment depression.

However, it is extremely important to determine whether the individual has had symptoms of mania or hypomania in the past, because the management of depression and bipolar disorder is completely different. Indeed, attempting to treat depression in someone with bipolar disorder may actually trigger a serious manic episode.

While any health worker can be trained to recognise the signs of other serious mental disorders, in many cases this will lead to referral to a specialist for diagnosis and treatment - especially if there is a chance that the patient presents a risk of harm to himself or others .

Where there is no mental health specialist nearby for referral, clinicians should be trained to manage more difficult cases or consult with a specialist remotely. Ultimately, an aim of the global health movement is to try to provide primary or community based care for as many psychiatric conditions as possible.

Before prescribing pharmacological treatment, a clinician should exclude any possible biological causes for the patient's symptom. For instance, symptoms of anxiety may also be caused by a range of medications, recreational drugs, excess caffeine, herbal supplements; or conditions such as adrenal insufficiency, hyperthyroidism, hypoglycemia, or hypoxia due to respiratory infections. ¹⁰⁷ Likewise, sleep or sexual disorders may have a number of physiological causes that should be investigated.

Suicide evaluation

Suicidal ideation, however, should prompt immediate further assessment, especially if the patient is likely to be under the influence of psychoactive substances and alcohol or in the midst of a delirium or psychosis. Some resources, such as the Columbia Manual suggest that signs of suicidal ideation should trigger an urgent referral to a trained specialist.

Risk factors and considerations in the evaluation of suicide risk

* Significant suicidal ideation*

* Specific intent or plan*; available means

* Hopelessness*

* Previous suicide attempts*

* Depressed mood, mood disorders*

* Family history of suicide or mood disorders*

* Schizophrenia, psychosis (not necessarily command hallucinations)*

* Organic mental syndromes*

* Intoxication with alcohol*, other substances

* Recent major loss, particularly through suicide

* Preoccupation with death

* Fantasies of reunion through death

* Homicidal rage

* Caucasian race*

*These factors have been documented as risk factors for suicide. ¹⁰⁸

However, specialist care may not always be available. In such situations, Dr Forstein's recommendations may prove useful: ¹⁰⁹

"It is important to ask specific and direct questions such as the following:

How are you feeling today?

Has it ever become so (painful, frustrating, difficult, frightening) that you have thought about giving up? About ending your life? Would you ever consider doing so? Under what circumstances have you considered this?

Do you currently have any thoughts or plans to hurt yourself?

"When a patient admits to suicidal ideation, inquire about whether he or she has thought about a specific plan to carry it out. Ask about the consequences of doing so, to the patient and those in the patient's life. Assess whether there is an intent to die, even if the methodology seems not very lethal to the provider, for example, the patient says he or she will take 20 pills which may not be biologically lethal, but psychologically is intended to end life. Providers are often reluctant to ask about suicidal ideation. Asking does not engender such ideas in people who do not have those thoughts to begin with. When a provider asks about suicidal ideation, it acknowledges the amount of pain and suffering the patient has endured, and often feels supportive and caring to the patient. It is also important to understand that the idea of suicide may provide to some a sense of ultimate control when it appears that control over the mind, body, or environment is slipping away. It would be unusual for anyone who experiences the shock of a new diagnosis of HIV, cancer or loss of function to not consider how much life is worth living and under what circumstances. Simply being able to verbalise the feeling of having ultimate control, and deciding if that is even a possibility, may help patients feel understood and more in control of their lives. Suicidal ideation may also be a sign of undiagnosed depression, under-treated pain, or other co-morbid conditions."

Therapeutic modalities

Recognition or diagnosis of mental health conditions must be accompanied by appropriate and evidence-based treatment. There are a number of therapeutic modalities available for people with HIV (and their loved ones) suffering from distress, bereavement, and diagnosed mental health disorders, including pharmacotherapy (such as antidepressant medications or antipsychotics) and an array of psychotherapeutic, counselling and social interventions. Drug therapies for mental health problems may work better if used along with special kinds of psychological therapy. Social interventions that target psychosocial risks factors associated with greater psychiatric morbidity may also lead to mental health improvements.

"Basic drug and psychotherapeutic treatments need to be made available at all levels of health care," wrote Prince et al in the lead Lancet article In the mental health series in 2007. ¹¹⁰ "Primary and secondary care providers should overcome their reluctance to treat patients with severe mental illnesses, and learn effective ways to interact and communicate with these patients."

The Columbia Manual recommends a systematic approach to treatment, starting with an inventory of local resources. ¹¹¹ For instance, is there a mental health specialist at the clinic or in the community? What counselling resources are available nearby? Are there patient support groups willing to accept new members? What spiritual or religious organisations provide services? Where would a patient who might need psychiatric hospitalisation be referred?

Clinics should also form partnerships with local palliative care organisations and hospices who may be able to provide additional support and map local resources.

Pharmacotherapies

Most people suffering from major depressive disorder and other serious mental health disorders in resource-limited settings do not get the medication they need. While the pharmaceutical management for bipolar disorder and schizophrenia is complex and should be initiated by a specialist or with specialist support, non-specialists should be able to treat depression.

Clinicians in resource-limited settings need to overcome their hesitancy to prescribe simple treatments for depression. ¹¹² However, doctors need to be aware that many of the psychiatric medications have drug interactions with antiretrovirals, while others may have serious over-lapping toxicity that the HIV clinician and mental health specialist should be aware of (see tables at the end of this edition, which list a number of the medications that are commonly prescribed for people with psychiatric disorders). Some of these medications are not marketed or affordable in some countries, though generics are available for many. That does not, however, mean that there will be access to a steady supply at the clinic, so programmes prescribing antidepressants should first assess the supply.

Close initial follow-up of people placed on these medications is essential. "It is not appropriate to diagnose a depression (with its inherent risk of suicide), start a medication (that may be initially agitating and cause other side-effects prior to any benefit) and have the patient follow-up in 3 to 4 weeks," wrote Triesman et al, suggesting weekly follow-up to watch for side-effects and titrate the dose. ¹¹³ Doses of all psychoactive drugs are generally started low and increased gradually to therapeutic range. It may take 6 to 8 weeks at that dose to see a clear benefit.

Recognising the hardship that weekly visits to the clinic could entail, the Columbia Manual recommends using a combination of follow-up methods including home visits, and phone calls.

Patients need to be reassured that early agitating effects of antidepressants will diminish, and that drugs may take some time to produce benefit.

WHO has also produced a series of resources and training materials on mental health and HIV. This one provides basic clinical information on psychiatric diagnosis and treatment for HIV care providers working in low income settings.

Although it is not a widespread problem yet in most resource limited settings, the WHO/WONCA report warns against prescribing mental health treatments for those who do not need them: "For example, in some countries health workers increasingly are prescribing antidepressants and anxiolytics for people who are experiencing unhappiness but do not meet the threshold for a mental disorder. Psychotropic medications are also sometimes overused in lieu of other modes of evidence-based treatment such as psychotherapy." ¹¹⁴

A note about St John's Wort: St John's Wort is an herbal supplement that is commonly used to treat mild depression.However, the herbal compound also interacts with, and should not be taken at the same time as protease inhibitors, or efavirenz or nevirapine, since it could reduce concentrations of these drugs, promoting the emergence of resistance and possibly contributing to treatment failure ( see research report).

Psychotherapies

There are literally hundreds of types of psychotherapy, each of which are meant to help individuals cope with problems, or take more charge of their lives and develop positive ways to deal with emotionally distressing life events or circumstances. There is some evidence to support the effectiveness of some of these approaches for some indications, but little in the way of data on their relative efficacy with each other or with pharmacotherapy.

The following descriptions of the broad categories of psychotherapy, were previously published in NAM's AIDS Treatment Update, July 2002.

The term cognitive behavioural therapy (CBT) pertains to a range of therapies that include behaviour therapy, behaviour modification, and cognitive therapy in various combinations. They are all theoretically distinct.

Behavioural approaches typically involve a formal behavioural analysis of a patient's problem. This is followed by an individually tailored application of techniques to change behaviour. Behaviour change is of paramount importance.

Cognitive approaches emphasise the role that cognitions play in mediating feelings and behaviour. The aim is to modify though processes directly. Therapy involves trying to identify automatic thought processes (such as hopelessness during depression), and tuition in how to recognise and challenge such thought processes. It helps people to connect life events to mood episodes, and encourages people to find new goals.

Long-term psychodynamic psychotherapy may last several years. It is based on psychoanalytic theory, and its distinctive feature is the resolution of unconscious conflicts. It makes direct use of the patient's experience of both the therapist and the therapeutic relationship. It aims to improve the patient's conscious understanding of difficulties and enable the assimilation of previously avoided, potentially painful experience. Brief psychotherapy may last for six months with weekly or bi-weekly sessions. It is focused on specific issues in the hope that the improved understanding it brings about will facilitate patients to effect a more lasting symptomatic change. This is achieved through processes that extend beyond the end of treatment. Patients who opt for this approach will need adequate capacity to tolerate frustration and psychic pain.

WHO has produced a booklet to assist 'second level' health care workers deal with problems that require psychotherapeutic counselling.

Group interpersonal psychotherapy or support groups are widely used as 'places of healing' to help people cope with trauma or grief, or to adjust to an HIV diagnosis. The groups may also act as a forum for obtaining advice in dealing with practical difficulties. Support groups are also widely used to reinforce positive behaviours in individuals fighting substance abuse.

Notably, a community-based randomised study of group therapy for depression was conducted in rural Uganda several years ago. ¹¹⁵ Thirty villages were randomly assigned to either receive sixteen weekly group therapy sessions or to be a control. The study involved over 200 participants. At the end of the study there was a mean reduction in depression severity score of 17.47 points in the group therapy group versus 3.55 points for controls (P < 0.001).

Collin's et al noted that "the community-based randomized control trial conducted in rural Uganda demonstrated the efficacy of interpersonal psychotherapy in a region with high HIV prevalence. Group IPT presents a low-cost intervention for people with HIV and those affected by HIV that does not require specialist mental health care providers to implement. With adaptation, such interventions may be usefully implemented in multiple cultural settings."

WHO has published a working tool on setting up and running support groups.

Counselling is usually conducted on a short-term basis (4 to 12 sessions), by individuals who have formal qualifications in counselling. Counselling may be used to help people to cope better with distress caused by immediate crises, to help people better understand their reactions to events, and to develop better coping strategies. It is particularly useful for the treatment of mild to moderate depression and interpersonal problems. It can be used to facilitate patients in determining a realistic assessment of their adherence to treatments, and in adjusting to the daily routine of taking ART.

Clinical psychologists may draw upon several different therapeutic methods during the course of treatment. Particular psychiatric problems do not preclude or require intervention with a particular therapy. At best, patients should be evaluated in a co-ordinated psychological treatment service that has expertise in a range of specific therapies.

There is at least one study from South Africa that found that one-on-one counselling and support groups could demonstrated no effect. ¹¹⁶ Of course, this may have been due to the style of the counselling or support being offered.

It is critically important that counsellors try to know the client's culture, according to Professor Alta Van Dyk: "For a century or more, traditional healing and Western forms of counselling and psychotherapy have operated side by side in Africa, but mostly in mutual isolation... Western counsellors must be aware of these differences if they want to render a helpful service to clients from a traditional background. To ignore a client's cultural background not only leads to misunderstanding, but can be anti-therapeutic and harmful." ¹¹⁷

WHO has also produced a guide on basic counselling as part of its HIV and mental health series.

Other forms of therapy

It may be that other types of interventions may be more culturally appropriate given how coping mechanisms vary from culture to culture.

Any number of activities that reduce stress, such as meditation, yoga, physical activity or dancing have been used to help people deal with depression or anxiety. For instance, one of Prof Van Dyk's studies noted that women from Zulu culture tended to deal with stress through group activities, such as singing, dancing and mutual discussions - rather than one on one or private activities. ¹¹⁸

Targetting psychosocial risk factors

While there are a growing number of researchers reporting the benefits of psychotherapies for people with HIV in resource-limited settings, others have voiced frustrations about extremely difficult psychosocial conditions. For instance, one poster by Burgess et al, at the South African AIDS Conference, described how community support groups were set up for mental health support and that some "soon developed into hubs of community action, geared at addressing social driven issues within their communities. ¹¹⁹ However, gains were often undermined by the effects of broader social issues such as poverty and a combination of AIDS-related and mental health related-stigma." In other words, in a context of unemployment and other stressors, the intervention was like pouring water into a leaky bucket.

"For mental health programming to have the greatest effect in HIV/AIDS impacted communities, it should also address underlying social factors within a community which can contribute to states of mental ill health," Burgess et al noted.

One of the factors that Dr Green's study in Vietnam focused on was the lack of employment - which many people cited as one of the main reasons for their poor quality of life. It might help to set up a support group or to go into counselling to talk about how bad having HIV and being unemployed makes someone feel, but it might be more effective to help the person find work, or to in some other way to give their life purpose.

"One of the first recommendations that came out of our study is to scale-up vocational training and employment schemes. This is difficult, it is always difficult - these types of interventions - and particularly with the current economic situation. However, there are a number of PEPFAR partners and others in Vietnam who are attempting to do this, with at least some small-scale successes thus far," said Green.

Other participants in her study cited their desire to start families, so another form of intervention in that setting would be to provide pre-conceptual counselling and to integrate family planning services into care and treatment programs. "This is happening on an ad-hoc-basis but there are really limited tools available, that can help provide us do more systematic assessment and support for people living with HIV," she said.

Whether seen as a therapeutic modality or perhaps as adjunctive therapy, such interventions can have a profound impact on people's lives.

The WHO/WONCA report described similar interventions following initial treatment for severe mental disorders in Neuquén, Argentina, a province with great economic disparities.

"After patients have been stabilised, the Austral (community-based rehabilitation centre) seeks to reintegrate people into the community and help them achieve economic independence. The clinic venue, a former private home in the centre of downtown, was chosen so that patients were not isolated and stigmatised, but rather received care in a central area. One of the most important achievements of the Austral has been to involve artisans, artists, farmers, educators, and other community members in the rehabilitation programme. An example of this is a work group of people with schizophrenia, who learnt farming skills and after two years were able to buy the land they farmed and construct a nursery. In addition, after receiving carpentry and other classes, the same group started selling good-quality wood products at the local market."

By giving people another focus other than their mental illness or their HIV infection, such interventions could in turn be crucial for the long term success of treatment and care, and help reduce the burden that these illnesses place upon the family. It might also be interesting to see how these interventions targeting psychosocial risk factors stack up against the conventional pharmacological and psychotherapeutic interventions.

One of the articles, by Patel et al, in the Lancet series on mental health, reviews the research on the different modes of therapy for the main mental health disorders, and concluded that while there may not be as much evidence in support of their use in low or middle-income countries as in the industrialised world, there was still enough to support their global scale up. 120 Given the suffering that people living with HIV and mental illness endure, this message is probably long overdue. However, it is important not to use broad-brush strokes when introducing interventions in different settings, especially as the only study to evaluate formal support services in people with HIV failed to demonstrate any impact.

"Given that individual counselling and support groups are what most policymakers consider to be a psychosocial service for PLHIV, more research on the benefits of these interventions would be valuable and could help direct the allocation of scarce human and financial resources," Dr Brandt wrote in her review. ¹²¹ Such data need to be gathered on the operational effectiveness of these therapies as they are rolled out - along with accurate data on the actual mental health needs now, and over time among people living, aging and dying with HIV in resource-limited settings.

Common psychiatric medications (availability varies by country)

Therapeutic dose ranges are listed because physicians and psychiatrists tend to start treatment with a low dose and gradually escalate the dose until a therapeutic effect is achieved.

All antidepressants may increase the risk of suicidality in children and adolescents, according to a 2004 FDA analysis based on studies lasting up to four months. This warning was subsequently extended to adults under the age of 25, but a comprehensive review published in 2007 found that the benefits of antidepressants in children and adolescents suffering major depressive disorder outweighed the risks.[i]

Many potential interactions remain clinically untested and the interactions outlined in the tables are largely theoretical based on the known metabolism of the psychiatric medications by the cytochrome P450 isoenzymes. Please consult a specialist for the most recent information regarding coadministration of the medications when there is a potential for interaction with protease inhibitors (PIs) or non-nucleoside reverse transcriptase inhibitors (NNRTIs).

Abbreviations: SSRI-selective serotonin reuptake inhibitors, q hs (before sleep).

Lithium carbonate

600 to

1800mg in divided dose

(varies with renal function)

Warnings: Lithium level monitoring needed for safety. Countraindicated in pregnancy or in people with kidney disease. Can cause nephrogenic diabetes insipidus, hypothyroidism, leukocytosis, seizures, cardiac conduction abnormalities. Lithium toxicity can begin with GI distress, confusion, tremors.

No drug interaction data available

Valproic acid

500 to 2000mg, titrated by

blood levels (50 to 100mg/mL)

Warnings related to liver toxicity, pancreatitis, teratogenicity. Other side effects include thrombocytopenia, GI distress, ataxia, tremors.

Possible interactions with some PIs & nevirapine. Ritonavir may decrease valproate concentrations. Increased lopinavir AUC by ~38%, no effect on valproate. However, case report of 48% reduction of valproate levels in one person taking Kaletra.

Carbamazepine

600-1600 mg in divided doses

Warning re aplastic anaemia. May also cause severe rash, agranulocytosis, and a syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH).

Carbamazepine reduces PI concentrations, including Kaletra (which should not be given once daily with carbamazepine), while PIs, especially ritonavir, increase carbamazepine concentrations and toxicity. Carbamazepine reduces efavirenz concentrations (decreasing C min by 47%). Both nevirapine and efavirenz decrease carbamazepine concentrations.

Antipsychotics
Most typical antipsychotics to varying degrees can cause extrapyramidal side-effects (EPS), which are due to dopamine blockade, resulting in tremors, slurred speech, anxiety, inability to move or conversely an inability to stop moving, dystonia, distress, paranoia, and parkinsonism. Prolonged dopamine blockade can lead to tardive dyskinesia (abnormal involuntary movements often of the tongue and mouth may cause breathing problems). People with HIV/AIDS and neurological problems may be more sensitive to EPS.[ii]

There are black box warnings on the atypical anti-psychotics; these are associated with increase risk of death in elderly patients. They also cause metabolic complications including hyperglycemia, diabetes, weight gain and high cholesterol.

Medications used in alcohol/opiate dependence/withdrawal

Sources http://www.hiv-druginteractions.org
FDA package inserts

Kobayashi J, Psychiatric issues. In Anderson, JR, ed. Guide to Clinical Care of Women with HIV, Rockville, Maryland: U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau, 2001.

Forstein, M. Psychiatric Problems, in A Clinical Guide to Supportive & Palliative Care for HIV/AIDS, edited by O'Neill JF, Selwyn PA, Schietinger H. US Health Resources and Services Administration, Washington DC, 2003.

Gallego L, Gordillo V, Catalan J. "Psychiatric and Psychological Disorders associated to HIV Infection," AIDS Reviews 2, no. 1: 49, 2000.

Treisman GJ, Angelino AF, Hutton HE. "Psychiatric Issue in the Management of Patients with HIV Infection," Journal of the American Medical Association 286, no. 22: 2857, 2001.

[i] Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA, MD. Clinical Response and Risk for Reported Suicidal Ideation and Suicide Attempts in Pediatric Antidepressant Treatment: A Meta-analysis of Randomized Controlled Trials. JAMA. 2007;297:1683-1696.

[ii] Fernandez F, Levy JK. Psychiatric diagnosis and pharmacotherapy of patients with HIV infection. In Tasman A, Goldfinger SM, Kaufman, eds. Review of Psychiatry, Vol.9. Washington, DC: American Psychiatric Press, 614, 1990

# data[].attributes.attachment_link.title
Mental health and HIV: a clinical review

# data[].attributes.attachment_link.description
ReviewersWith additional reporting by Lance Sherriff