The mental health of HIV-positive adolescents
The Lancet, UK
Khameer Kidiaemail, Chiratidzo Ndhlovu, Shamiso Jombo, Melanie Abas, Azure T Makadzange
The 2013 WHO guidelines1 for the care of adolescents living with HIV/AIDS argue for the active engagement of HIV-positive adolescents themselves in the delivery of care for this population. However, these guidelines give few examples of how this engagement has been achieved in different contexts and provide only few recommendations on best practices. We believe that adolescents living with HIV can be important in the delivery of mental health services for their peers through a task-shifting approach, in which these adolescents are trained in basic psychological therapies.
Improved access to antiretroviral therapy and slow disease progression have helped children who were perinatally infected with HIV to survive to become adolescents. Therefore, the psychosocial wellbeing of these HIV-positive adolescents has become a major concern for health-care providers and policy makers.2, 3 The high burden of poor mental health in adolescents with HIV is worsened by stigma, sexual abuse, and poverty, and puts this group at increased risk for poor adherence to antiretroviral therapy.2, 4 Health-care staff shortages and other constraints make mental health care access for this population in sub-Saharan Africa inadequate.5
A notable absence of culturally adapted, context-specific recommendations for addressing the mental health needs of these adolescents worsens the situation. For example, age-appropriate interventions for the disclosure of HIV status to adolescents or for any other common mental disorders such as depression and anxiety are scarce. To create the most effective interventions for adolescents with HIV, mental health investigators need to design rigorous studies to establish culturally relevant psychosocial interventions for adolescents living with HIV, which take into account the particular needs and preferences of this growing population.
Regardless of the outcomes of future investigations in low-income countries, severe shortages in mental health workers remain a barrier to effective interventions. For example, in Ghana, only 11 psychiatrists are available for a population of 25 million people.6 Pioneers in global mental health advocate for a task-shifting approach to tackle workforce deficiencies.7 This approach typically includes the training of lay community members in the delivery of basic psychosocial care such as cognitive behavioural therapy and problem-solving therapy. The task-shifting approach has proven effective for adults in settings with high HIV prevalence,8 but this approach has not been tested in adolescents with HIV.
Throughout Africa, adolescent HIV-positive peer educators assist in the health care of adolescents with HIV both in a formal and an informal basis.5, 9 During a qualitative study9 undertaken by investigators at the largest adolescent HIV clinic in Zimbabwe, a boy aged 18 years summarised the benefits of peer-based psychosocial support:
“At home alone I start thinking about my mother passing away. Here, the others counselled me in the support group. It helps calm my thoughts and removes bad thoughts. Here, you cannot blame yourself or say that you are the only one”.
Zvandiri, a community-based organisation in Zimbabwe, trains adolescents with HIV to help provide HIV testing, counselling, and training of their peers with HIV.10 The success of Zvandiri has led the Ministry of Health and Child Care in Zimbabwe to scale up the programme to the national level.1
Guardians and health-care providers might argue that these adolescents are not mature enough to be given responsibility for the mental health care of their peers, or that their status as both patients and health-care providers might represent a conflict of interest. We acknowledge these challenges for policymakers of peer support programs. However, our clinical and investigational experience shows that if the adolescents are selected carefully and trained well, they can become mature and competent facilitators in the delivery of mental health care for one another. They can even thrive in such an environment. It is time to think seriously about implementing psychosocial interventions that are both age appropriate and culturally appropriate, and that are delivered by reliable, well trained HIV-positive adolescents. Although several successful models exist for the incorporation of these adolescents in the delivery of mental health services to their peers, no randomised trials have been undertaken to develop an overarching framework that can be adapted and tested in a variety of settings. Moreover, models that involve adolescent peers do not train adolescents in specific psychological treatments such as cognitive behavioural therapy or problem-solving therapy, as has been done for lay health workers in task-shifting approaches.
In view of the global call to action for the integration of mental health care into HIV services,11, 12 the interest in the expansion of mental health care for adolescents with HIV,2, 5 and the preliminary evidence that suggests that these adolescents can successfully assist one another, we call for investigators and policy makers to develop and validate true task-shifting interventions that formally involve trained adolescents with HIV for the mental health care of other adolescents with HIV. Such interventions would recognise adolescents with HIV as important members of the health-care teams that confront the challenges presented by the adolescent HIV epidemic. Moreover, the training of these adolescents in the delivery of mental health care would build skills and aptitudes in this young population with high rates of orphanhood, limited opportunities, and substantial barriers to access to formal education.
ATM reports personal fees from GSK Consulting, outside the submitted work. KK, CN, SJ, and MA declare no competing interests.
We thank Lucie Cluver, Nicholas Micinski, and Laura Nelson for their input.