Closing the treatment gap for depression co-morbid with HIV in South Africa: Voices of afflicted women

Abstract

This Background: In South Africa the rising comorbidity of mental\rdisorders with other non-communicable and\rcommunicable diseases, particularly in people living with HIV/AIDS\r(PLWHA), has helped raise the public health priority of mental ill-health.\rDepression, in particular, compromises anti-retroviral treatment (ART) adherence and virological suppression, thus threatening the effectiveness of South\rAfrica’s ART programme. Given that evidence-based treatment for depression comprises\rmedication and/ or Western-derived psychotherapies, responding to the current\rinterest in expanding mental health services for PLWHA demands an understanding\rof how best to provide culturally competent care within existing resource\rconstraints. Aim: To explore the context and local understandings of depression\rin women living with HIV to inform the development of contextually appropriate\rmental health services that could be delivered within existing resource\rconstraints inSouth Africa. Method: Semi-structured qualitative interviews were held\rwith 35 women living with HIV in South Africa who met the diagnostic criteria\rfor a major depressive disorder. Results: Being HIV-positive per se was not\rreported to be a major cause of depression. Instead, a number of social factors\rwere reported. These included stigma and\rdiscrimination, poverty, and stressful life events. Symptoms of depression, especially social withdrawal, negative ruminating thoughts and excessive\rworry suggestive of comorbid anxiety, functioned to exacerbate and trap women\rin a negative depressive cycle. Social support emerged as a dominant coping\rstrategy. Group-based interventions, which afford greater opportunities for\rimproved social support, were mooted as the most appropriate intervention by the\rmajority of participants. Individual counselling provided through a home\rvisitation programme was suggested for those who were too ill or too poor to\rattend clinics. Task sharing was also endorsed. Conclusion: The need for multi-sector engagement in mental health promotion to address factors that trigger,\rmaintain and exacerbate depression at a community level in PL-WHA is\rhighlighted. The triggers, symptoms and local coping strategies employed by\rafflicted women in this study suggest a resonance with Western derived\revidence-based psychological therapies. In relation to delivery channels, there\rwas support for the provision of group interventions or home-based individual\rcounselling using a task sharing model.