Prevalence and correlates of probable post-traumatic stress disorder and common mental disorders in a population with a high prevalence of HIV in Zimbabwe.

Background: We investigated the prevalence of and factors associated with post-traumatic stress disorder (PTSD) and common mental disorders (CMDs), which include depression and anxiety disorders, in a setting with a prevalence of high human immunodeficiency virus (HIV) within a primary care clinic, using the PTSD Checklist for DSM-5 and the 14-item Shona Symptom Questionnaire, both locally validated screening tools. Methods: A cross-sectional survey was carried out with adult patients (n = 204) from the largest primary care clinic facility in Harare, Zimbabwe, in June 2016. Results: A total of 83 patients (40.7%) met the criteria for probable PTSD, of whom 57 (69.5%) had comorbid CMDs. Among people living with HIV, 42 (55.3%) had PTSD. Probable PTSD was associated with having experienced a negative life event in the past 6 months [adjusted odds ratio (OR) 3.73, 95% confidence interval (CI) 1.49-9.34] or screening positive for one or more CMD (adjusted OR 6.48, 95% CI 3.35-2.54). Conclusion: People living with HIV showed a high prevalence of PTSD and CMD comorbidity. PTSD screening should be considered when the CMD screen is positive and there is a history of negative life events

Positioning for success: building capacity in academic competencies for early-career researchers in sub-Saharan Africa.

BACKGROUND: Capacity building is essential in low- and middle-income countries (LMICs) to address the gap in skills to conduct and implement research. Capacity building must not only include scientific and technical knowledge, but also broader competencies, such as writing, disseminating research and achieving work-life balance. These skills are thought to promote long-term career success for researchers in high-income countries (HICs) but the availability of such training is limited in LMICs. METHODS: This paper presents the contextualisation and implementation of the Academic Competencies Series (ACES). ACES is an early-career researcher development programme adapted from a UK university. Through consultation between HIC and LMIC partners, an innovative series of 10 workshops was designed covering themes of self-development, engagement and writing skills. ACES formed part of the African Mental Health Research Initiative (AMARI), a multi-national LMIC-led consortium to recruit, train, support and network early-career mental health researchers from four sub-Saharan African countries. RESULTS: Of the 10 ACES modules, three were HIC-LMIC co-led, four led by HIC facilitators with LMIC training experience and three led by external consultants from HICs. Six workshops were delivered face to face and four by webinar. Course attendance was over 90% and the delivery cost was approximately US$4500 per researcher trained. Challenges of adaptation, attendance and technical issues are described for the first round of workshops. CONCLUSIONS: This paper indicates that a skills development series for early-career researchers can be contextualised and implemented in LMIC settings, and is feasible for co-delivery with local partners at relatively low cost

Scaling up interventions for depression in sub-Saharan Africa: lessons from Zimbabwe.

BACKGROUND: There is a dearth of information on how to scale-up evidence-based psychological interventions, particularly within the context of existing HIV programs. This paper describes a strategy for the scale-up of an intervention delivered by lay health workers (LHWs) to 60 primary health care facilities in Zimbabwe. METHODS: A mixed methods approach was utilized as follows: (1) needs assessment using a semi-structured questionnaire to obtain information from nurses (n = 48) and focus group discussions with District Health Promoters (n = 12) to identify key priority areas; (2) skills assessment to identify core competencies and current gaps of LHWs (n = 300) employed in the 60 clinics; (3) consultation workshops (n = 2) with key stakeholders to determine referral pathways; and (4) in-depth interviews and consultations to determine funding mechanisms for the scale-up. RESULTS: Five cross-cutting issues were identified as critical and needing to be addressed for a successful scale-up. These included: the lack of training in mental health, unavailability of psychiatric drugs, depleted clinical staff levels, unavailability of time for counseling, and poor and unreliable referral systems for people suffering with depression. Consensus was reached by stakeholders on supervision and support structure to address the cross-cutting issues described above and funding was successfully secured for the scale-up. CONCLUSION: Key requirements for success included early buy-in from key stakeholders, extensive consultation at each point of the scale-up journey, financial support both locally and externally, and a coherent sustainability plan endorsed by both government and private sectors

Grand Challenges: Improving HIV Treatment Outcomes by Integrating Interventions for Co-Morbid Mental Illness.

In the fourth article of a five-part series providing a global perspective on integrating mental health, Sylvia Kaaya and colleagues discuss the importance of integrating mental health interventions into HIV prevention and treatment platforms. Please see later in the article for the Editors' Summary

Common mental health and emotional and behavioural disorders among adolescents and young adults in Harare and Mashonaland East, Zimbabwe: a population-based prevalence study.

OBJECTIVES: To estimate the prevalence of common mental health disorders (CMDs) and emotional and behavioural disorders among young people and to explore the correlates of CMDs risk. SETTING: Five urban and periurban communities in Harare and Mashonaland East, Zimbabwe DESIGN: Population-based cross-sectional study PARTICIPANTS: Young people aged 13-24 years living in households in the study areas. OUTCOME MEASURES: The primary outcome was the proportion of participants screening positive for probable CMDs defined as a Shona Symptoms Questionnaire (SSQ) score ≥8. Secondary outcomes were emotional and behavioural disorders measured using the Strength and Difficulties Questionnaire (SDQ), and adjusted ORs for factors associated with CMD. RESULTS: Out of 634 young people, 37.4% (95% CI 33.0% to 42.0%) screened positive for probable CMDs, 9.8% (95% CI 7.5% to 12.7%) reported perceptual symptoms and 11.2% (95% CI 9.0% to 13.8%) reported suicidal ideation. Using UK norms to define normal, borderline and abnormal scores for each of the SDQ domains, a high proportion (15.8%) of Zimbabwean young people had abnormal scores for emotional symptoms and a low proportion had abnormal scores for hyperactivity/inattention scores (2.8%) and prosocial scores (7.1%). We created local cut-offs for the emotional symptoms, hyperactivity/attention and prosocial SDQ domains. The odds of probable CMDs increased with each year of age (OR 1.09, p<0.001) and was higher among those who were out of school and not working compared with those in school or working (adj. OR 1.67 (1.07, 2.62), p=0.04). One in five participants (22.1%) were referred immediately for further clinical assessment but uptake of referral services was low. CONCLUSIONS: We observed a high prevalence of symptoms of CMDs among general population urban and peri-urban young people especially among those with no employment. There is a need for more accessible and acceptable youth-friendly mental health services

Trauma history and depression predict incomplete adherence to antiretroviral therapies in a low income country.

As antiretroviral therapy (ART) for HIV becomes increasingly available in low and middle income countries (LMICs), understanding reasons for lack of adherence is critical to stemming the tide of infections and improving health. Understanding the effect of psychosocial experiences and mental health symptomatology on ART adherence can help maximize the benefit of expanded ART programs by indicating types of services, which could be offered in combination with HIV care. The Coping with HIV/AIDS in Tanzania (CHAT) study is a longitudinal cohort study in the Kilimanjaro Region that included randomly selected HIV-infected (HIV+) participants from two local hospital-based HIV clinics and four free-standing voluntary HIV counselling and testing sites. Baseline data were collected in 2008 and 2009; this paper used data from 36 month follow-up interviews (N = 468). Regression analyses were used to predict factors associated with incomplete self-reported adherence to ART. INCOMPLETE ART ADHERENCE WAS SIGNIFICANTLY MORE LIKELY TO BE REPORTED AMONGST PARTICIPANTS WHO EXPERIENCED A GREATER NUMBER OF CHILDHOOD TRAUMATIC EVENTS: sexual abuse prior to puberty and the death in childhood of an immediate family member not from suicide or homicide were significantly more likely in the non-adherent group and other negative childhood events trended toward being more likely. Those with incomplete adherence had higher depressive symptom severity and post-traumatic stress disorder (PTSD). In multivariable analyses, childhood trauma, depression, and financial sacrifice remained associated with incomplete adherence.\ud This is the first study to examine the effect of childhood trauma, depression and PTSD on HIV medication adherence in a low income country facing a significant burden of HIV. Allocating spending on HIV/AIDS toward integrating mental health services with HIV care is essential to the creation of systems that enhance medication adherence and maximize the potential of expanded antiretroviral access to improve health and reduce new infections

A pilot randomized controlled trial of a stepped care intervention package for depression in primary care in Nigeria

Background Depression is common in primary care and is often unrecognized and untreated. Studies are needed to demonstrate the feasibility of implementing evidence-based depression care provided by primary health care workers (PHCWs) in sub-Saharan Africa. We carried out a pilot two-parallel arm cluster randomized controlled trial of a package of care for depression in primary care. Methods Six primary health care centers (PHCC) in two Local Government Areas of Oyo State, South West Nigeria were randomized into 3 intervention and 3 control clinics. Three PHCWs were selected for training from each of the participating clinics. The PHCWs from the intervention clinics were trained to deliver a manualized multicomponent stepped care intervention package for depression consisting of psychoeducation, activity scheduling, problem solving treatment and medication for severe depression. Providers from the control clinics delivered care as usual, enhanced by a refresher training on depression diagnosis and management. Outcome measures Patient’s Health Questionnaire (PHQ-9), WHO quality of Life instrument (WHOQOL-Bref) and the WHO disability assessment schedule (WHODAS) were administered in the participants’ home at baseline, 3 and 6 months. Results About 98% of the consecutive attendees to the clinics agreed to have the screening interview. Of those screened, 284 (22.7%) were positive (PHQ-9 score ≥ 8) and 234 gave consent for inclusion in the study: 165 from intervention and 69 from control clinics. The rates of eligible and consenting participants were similar in the control and intervention arms. In all 85.9% (92.8% in intervention and 83% in control) of the participants were successfully administered outcome assessments at 6 months. The PHCWs had little difficulty in delivering the intervention package. At 6 months follow up, depression symptoms had improved in 73.0% from the intervention arm compared to 51.6% control. Compared to the mean scores at baseline, there was improvement in the mean scores on all outcome measures in both arms at six months. Conclusion The results provide support for the feasibility of conducting a fully-powered randomized study in this setting and suggest that the instruments used may have the potential to detect differences between the arms