BRITISH JOURNAL OF PSYCHIATRY (2005), 187, 1^3 EDITORIAL

Integrating in global initiatives side-effects of some antiretroviral therapy (notably efavirenz); and the social difficul- for HIV/AIDS ties faced as a result of stigma and discrimi- nation (Chandra et aletal, 1998; ElsEls,1998; et aletal, 1999;,1999; TostesTostes et aletal, 2004). A significant proportion MELVYN C. FREEMAN, VIKRAM PATEL, PAMELA Y. COLLINS of people with HIV/AIDS in some devel- and JOSE M. BERTOLOTE oped countries receive some form of psychosocial and/or mental health inter- vention, including psychotropic medi- cation, psychotherapy and other services (Vitiello(Vitiello et aletal, 2003; Green & Smith, 2004). We lack data from developing coun- Summary A more prominent role is the Global Fund to Fight AIDS, Tubercu- tries on how many people with HIV/AIDS needed for mentalhealthinterventionsin losis and Malaria, jointly to declare the lack seek mental health services and receive of access to antiretroviral drugs to be a treatment, but anecdotal evidence suggests global HIV/AIDS initiatives ^ such as the global health emergency. Together they that only a small number of HIV treatment World Health Organization‘3 by 5’ launched the ‘Treat 3 Million by 2005’ programmes in these settings provide men- Initiative.Significant numbers of infected (‘3 by 5’) Initiative (World Health tal health services, and only a fraction of people have, or develop, mental health Organization, 2003). those with HIV/AIDS receive mental problems, andthisand this often adverselyimpacts The emphasis of these new initiatives healthcare.healthcare. has been, to a large extent, focused on The second question is whether on HIV/AIDStreatment and adherence. ensuring the reliable and proper provision providing mental health interventions Integrating psychiatric and psychosocial of evidence-based antiretroviral treatments. improves the medical and treatment out- interventions should benefit both the In July 2004, a group of 18 mental health comes of people with HIV/AIDS. Would mental and the physical health of people professionals (see Appendix) from devel- the expected improvement in mental health oped and developing countries met in outcomes (such as reduced rates of depres- living with HIV/AIDS. Johannesburg, South Africa, under the sion) influence the course and outcome of Declaration of interest None.None. auspices of the WHO. The group’s task the viral ? Ickovics et aletal (2001) have was to consider how mental health demonstrated that depressive symptoms in should be integrated into the ‘3 by 5’ women with HIV are associated with dis- One of the most pressing international to support the programme’s goals and ease progression. Moreover, the success of health problems of our time is HIV/AIDS. objectives. This editorial presents the HIV treatment programmes requires that In 2004 an estimated 39.4 million people key themes arising from this meeting. participants adhere to long-term therapy were living with HIV and over 3 million These themes and recommendations em- with multiple drugs, some of which may people died of the disease (UNAIDS, phasise the role of, and opportunities for, produce unpleasant side-effects. Numerous 2004). Preventing the spread of the pan- mental health issues in global initiatives studies have found that mental disorders demic and providing treatment to infected for HIV care and treatment in developing are a significant impediment to adherence individuals – especially in developing countries.countries. to antiretroviral therapy (Hinkin et aletal,, countries – present vexing challenges, de- 2002; Ammassari et aletal, 2004). In addition spite increased understanding of the risk to the treatment of specific mental dis- factors of the condition and the develop- orders, several behavioural interventions ment of improved and less burdensome WHY MENTAL HEALTH derived from mental health practice may treatment regimens. Of the 6 million people MATTERS TO HIV/AIDS also contribute to adherence. These include globally who require antiretroviral therapy, TREATMENT PROGRAMMES motivational interviewing, cognitive– only 8% receive it – with considerable geo- IN DEVELOPING COUNTRIES behavioural therapy and group supportive graphical inequity. For example, in the therapy (Ironson et aletal, 2005; Parsons etet region of the Americas 84% of persons Four major questions were considered alal, 2005). A recent study from Peru, for needing antiretroviral therapy receive this to make the case for the integration of example, demonstrated how group treatment, whereas in Africa only 2.2% of mental health into HIV/AIDS treatment therapy could improve adherence to an estimated 4.4 million in need do so programmes. treatment for tuberculosis in patients (World Health Organization, 2003). Mil- First, why are concerns about mental with multidrug-resistant tuberculosis lions continue to die unnecessarily, with health relevant for people with HIV/AIDS? (Sweetland(Sweetland et aletal, 2002).,2002). not only devastating consequences at a per- We identified at least five distinct mental Thus, mental health issues are closely sonal and family level, but also major social health-related issues that would be relevant associated with the experience of living and economic consequences. In September to HIV/AIDS programmes: cognitive im- with HIV/AIDS and with the course and 2003, this dire situation prompted Lee pairment and dementia due to viral infec- management of the disease. The third ques- Jong-Wook, Director-General of the World tion of the brain; depression and anxiety tion is whether providing mental health Health Organization (WHO), Peter Piot, due to the impact of the infection on the interventions is feasible. Specifically, can Executive Director of UNAIDS, and person’s life; alcohol and drug use, which these interventions be provided in settings Richard Feachem, Executive Director of contribute to risk behaviours; the psychiatric that are already desperately short of mental

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health resources? Two opportunities are RECOMMENDATIONS are prioritised by agencies implementing evident. First, the roll-out of the ‘3 by 5’ treatment programmes. initiative involves intensive and widespread Three broad recommendations were made The ‘3 by 5’ initiative is a massive training in the WHO Integrated Manage- for the integration of mental health in the response by the WHO to an enormous ment of Adolescent and Adult Illnesses ‘3 by 5’ and other HIV/AIDS treatment global health crisis. Its implementation (IMAI) (World Health Organization, programmes in developing countries. (and its undoubted continuation in some 2004); by including mental health in the First, a successful HIV/AIDS inter- form) must include effective alleviation of IMAI guidelines and ensuring adequate vention programme must include the psychiatric symptoms and promote the training in basic medical and psychological assessment of mental disorders and their emotional well-being of people living with management of disorders, a holistic and appropriate management as part of the nor- HIV/AIDS.HIV/AIDS. integrated primary mental healthcare mative service. There is a need to develop approach can be promoted. Moreover, we appropriate materials and models for the believe that, in the case of HIV/AIDS, there delivery of mental healthcare within the APPENDIX is already a substantial human resource parameters of the ‘3 by 5’ initiative based base among the primary care providers on the principles of affordability, accept- The following mental health professionals attended who are ideally placed to provide front-line ability and availability. The front-line pro- thethe‘3by5andMentalHealth’meetingin ‘3 by 5 and Mental Health’ meeting in mental healthcare in the ‘3 by 5’ initiative. viders should be the existing primary Johannesburg in 2004, and contributed to the These providers are the growing number healthcare workers and counsellors who strategic analysis and work plan: Dr Atalay Alem (Ethiopia), Dr Jose Bertolote of HIV/AIDS counsellors being trained in have received additional training and rele- ( WHO), Dr Jose Catalan (UK), Dr Pamela Collins most developing countries to conduct pri- vant materials – although caution is needed (USA), Dr Francine Cournos (USA), Professor marily pre-test and post-test counselling as so that too many functions are not expected Melvyn Freeman (South Africa/WHO), Dr Sandy part of voluntary counselling and testing of the same individuals. Additional skilled Gove (WHO), Dr Mark Halman (Canada), Dr programmes (Kaaya & Fawzi, 1999). These personnel may be essential in certain situa- Kevin Kelly (South Africa), Ray Lazarus (South counsellors, who come from a variety of tions. When possible, an established re- Africa), Dr Joseph Mbatia (Tanzania), Professor Dan Mkize (South Africa), Dr Vikram Patel (), Kerry educational backgrounds and health disci- lationship with local mental health service Saloner (South Africa), Vernon Solomon (South plines, are trained in counselling skills such providers should be encouraged, to pro- Africa), Professor Leslie Swartz (South Africa), as giving information, listening to the per- mote a collaborative model of care that in- Annika Sweetland (USA/Peru), Dr Rita Thom sonal concerns and worries of the person cludes supervision and support for the first- (South Africa). with HIV/AIDS, and problem-solving. level workers as well as clearly defined Counsellors recognise that many people referral pathways to specialist services. will develop adverse emotional reactions The second recommendation is the need REFERENCES in response to testing, and the counselling to support research on mental health and Ammassari, A., Antinori, A., Aloisi, M. S., et aletal is partly aimed at minimising these reac- HIV/AIDS. Despite the fact that over 90% (2004) Depressive symptoms, neurocognitive tions. Mental disorders encompass a conti- of the burden of HIV/AIDS is in developing impairment, and adherence to highly active nuum from mild distress to frank clinical countries, little research in this area antiretroviral therapy among HIV-infected persons. Psychosomatics,, 55,394^402., 394^402. conditions, and some HIV counsellors emerges from these countries. We recom- may already possess the skills to manage mend that the immediate priorities for Chandra, P.S., Ravi,V., Desai, A., et al (19 9 8) Anxiety and depression among HIV-infected heterosexuals a the milder emotional problems (Vollmer research must be linked to the new treat- report from India. Journal of Psychosomatic Research 4545,, & Valadez, 1999). ment programmes. Two key research ques- 401^409. Finally, what is the potential impact on tions were identified: what is the impact of Els, C., Boshoff,W. & Scott, C. (1999) Psychiatric the status of mental healthcare in develop- mental disorders on the course and out- co-morbidity in South African HIV/AIDS patients. South ing countries of a substantive, vertical, come of HIV/AIDS and the efficiency of African Medical Journal, 8989, 992^995. disease-focused programme such as the the antiretroviral therapy programmes (for Green,G.Green, G. & Smith, R. (2004) The psychosocial and healthcare needs of HIV positive people in the United ‘3 by 5’ initiative? We believe that the example, immune status indicators, adher- Kingdom: a review. HIV ,, 55 (suppl. 1), 5^46. integration of mental health into this in- ence with therapy); and what is the feasibil- Hinkin, C. H., Castellon, S. A., Durvasula, R. S., et aletal itiative presents an enormous opportunity ity, effectiveness and cost-effectiveness of (2002) Medication adherence among HIV+ adults: to strengthen the status of mental health mental health interventions? effects of cognitive dysfunction and regimen complexity. in services in developing Finally, advocacy is needed from a NeurologyNeurology,, 5959,1944^1950. countries. It provides an important chance range of stakeholders to highlight the role Ickovics, J. R., Hamburger, M. E.,Vlahov, D., et al to improve the health of people with of mental health in HIV/AIDS treatment (2001) Mortality,CD4 cell count decline, and depressive symptoms among HIV-seropositive women. JAMAJAMA,, 285,, HIV specifically, and to expand mental programmes. Sadly, although such pro- 1466^1474.1466^1474. health services in general health services. grammes are well recognised in developed Ironson, G.,Weiss, D., Lydston, D., et al (2005) TheThe These actions would increase the mental countries, mental health perspectives are impact of improved self-efficacy on HIV viral load and health resource base in many countries notable only for their absence in the pro- distress in culturally diverse women living with AIDS: the several-fold (by including general health grammes being rolled out in developing SMART/EST Women’s Project. AIDS CareCareAIDS ,, 1717, 222^236 workers and counsellors as de factodefacto countries. The incremental cost of such a Kaaya, S. F. & Fawzi, M.C. (1999) HIV counseling in sub-Saharan Africa. Aids,, 13,1577^1579. mental health personnel) and increase the component is likely to be a fraction of the awareness of the burden and managementagementman total programme cost. Moreover, people Parsons, J.T.,J. T., Rosof, E., Punzalan, J. C., et aletal (2005)(2005) Integration of motivational interviewing and cognitive of mental disorders in the general health accessing HIV/AIDS services must demand behavioural therapy to improve HIV medication sector.sector. mental health services to ensure that these adherence and reduce substance use among HIV-

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positive men and women: results of a pilot project. AIDS Patient Care and STDs,, 19,31^39., 31^39. MELVYN FREEMAN, MA (Clin Psych),Chief Research Specialist, Human Sciences Research Council, Pretoria, South Africa; VIKRAM PATEL, MRCPsych, PhD,Reader in International Mental Health, London School of Sweetland, A., Albujar, J. A. & Echevarria, D. G. Hygiene and Tropical Medicine,UK;Medicine, UK; PAMELAY.COLLINS, MD,MPH,MD, MPH, Assistant Professor of Clinical Psychiatry in (2002)(2002) Enhancing adherence: the role of group ,Departments of Psychiatry and Epidemiology,Columbia University,New York State Psychiatric psychotherapy in the treatment of MDR-TB in urban Peru. In World Mental Health Casebook: Social and Mental Institute,USA;Institute,USA;JOSE JOSE BERTOLOTE,BERTOLOTE,MD,Coordinator,Management MD,Coordinator,Management of Mental and Brain Disorders,Disorders,Department Department of Health Programmes in Low-income Countries (eds Mental Health and Substance Abuse,Geneva, Switzerland A.Cohen,A. Cohen, A.KleinmanA. Kleinman & B. Saraceno), pp. 51^79.New51^79. New York:Kluwer Academic/Plenum. Correspondence: Professor Melvyn C.Freeman,C.Freeman,HumanHuman Sciences Research Council,Council,Private Private Bag X41, Pretoria 0001, South Africa. E-mail: mfreeman@@hsrc.ac.za

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