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 disorders with other no communicable and communicable diseases, particularly in people living with HIV/AIDS (PLWHA), has helped raise the public health priority of mental ill-health. Depression, in particular, compromises anti-retroviral treatment (ART) adherence and virological suppression, thus threatening the effectiveness of South Africa's ART programme. Given that evidence-based treatment for depression comprises medication and/or Western-derived psychotherapies, responding to the current interest in expanding mental health services for PLWHA demands an understanding of how best to provide culturally competent care within existing resource constraints. Aim: To explore the context and local understandings of depression in women living with HIV to inform the development of contextually appropriate mental health services that could be delivered within existing resource constraints in South Africa. Method: Semi-structured qualitative interviews were held with 35 women living with HIV in South Africa who met the diagnostic criteria for a major depressive disorder. Results: Being HIV-positive per se was not reported to be a major cause of depression. Instead, a number of social factors were reported. These included stigma and discrimination, poverty, and stressful life events. Symptoms of depression, especially social withdrawal, negative ruminating thoughts and excessive worry suggestive of comorbid anxiety, functioned to exacerbate and trap women in a negative depressive cycle. Social support emerged as a dominant coping strategy. Group-based interventions, which afford greater opportunities for improved social support, were mooted as the most appropriate intervention by the majority of participants. Individual counselling provided through a home visitation programme was suggested for those who were too ill or too poor to attend clinics. Task sharing was also endorsed. Conclusion: The need for multisector engagement in mental health promotion to address factors that trigger, maintain and exacerbate depression at a community level in PLWHA is highlighted. The triggers, symptoms and local coping strategies employed by afflicted women in this study suggest a resonance with Western derived evidence-based psychological therapies. In relation to delivery channels, there was support for the provision of group interventions or home-based individual counselling using a task sharing model.