MENTAL HEALTH AND HIV/AIDS IN LOW-INCOME COUNTRIES
The position of the World Federation for Mental Health is that lack of mental health care for persons infected or affected by HIV/AIDS in low-income countries is causing undue suffering and loss of quality of life, and undermining the effectiveness of HAART, Psychosocial Support and other crucial HIV/AIDS programs
Federation for Mental Health (WFMH) is made up of organizations
and individual members representing all mental health
professional disciplines, service users, carers and citizen
advocates from over 100 countries. WFMH has noted that, whereas
people infected or affected by HIV/AIDS in higher income
countries have access to a wide range of mental health services
from prevention to care and rehabilitation, mental health
services in low-income countries are generally lacking, or
under-utilized due to ignorance, or stigma associated with
mental health. In this position statement, WFMH calls for
recognition of and response to the impact of this deficiency on
the quality of life of survivors and on the effectiveness of
Highly Active Anti-Retroviral Treatment (HAART), Psychosocial
Support and other HIV/AIDS programs in low-income countries.
The HIV/AIDS epidemic in low-income countries
The declaration following the 2006 United Nations General Assembly’s (UNGASS) High-Level Meeting on AIDS reaffirmed that HIV/AIDS constitutes a global emergency that requires an exceptional and comprehensive global strategy. More than 25 million people have died since the onset of the epidemic a quarter of a century ago, and 15 million have been orphaned. There are 14000 new infections every day, and 8000 deaths. Forty million people are currently living with HIV, more than 95 percent of whom are in developing countries. While the pandemic affects every region of the world, Africa, in particular Sub-Saharan Africa, remains the worst affected region.
Although the declaration reaffirms that access to medication is one of the fundamental elements for the achievement of physical health, it recognizes that many other factors must be addressed for the pandemic to be reversed: these include gender discrimination, stigma, poverty, and the knowledge and behaviour of youth, as well as human resource deficiencies. The declaration also asserts that addressing the vulnerabilities of affected and infected children and supporting their caregivers is a priority.
Current status of global HIV/AIDS interventions
The global HIV/AIDS response includes many initiatives coordinated by or in collaboration with the Joint United Nations Program on HIV/AIDS (UNAIDS) and supported by the Global Fund. Member states adopted the first specific global target against HIV/AIDS at the UN General Assembly (UNGASS) in July 1999, and the Global Strategy Framework and The Declaration of Commitment followed in 2000 and 2001 respectively. UNICEF and other organizations published The Framework for the Protection, Care and Support of Orphans and Vulnerable Children living in a world with HIV/AIDS in 2004. In 2003 the World Health Organisation committed to getting anti-retroviral treatment (ART) for 3 million people living with HIV/AIDS in poor countries by 2005 (3 by 5 Program). In 2004, the WHO’s Department of Mental Health and Substance Abuse began an initiative to integrate mental health into the 3 by 5 program. Many nongovernmental and faith-based organizations also contribute to the global HIV/AIDS response, such as the International HIV/AIDS Alliance, established in 1993 to support community action on AIDS in developing countries, and the International Council of Aids Service Organizations (ICASO).
The report of the Secretary-General to the 2006 UNGASS Meeting on AIDS stated that the epidemic continues to outpace the global response: only about one in five people in low- and middle-income countries who need antiretroviral drugs are currently obtaining them, and services to prevent mother-to-child transmission reach fewer than 10% of those needing them. Only one in four youth correctly identify ways of preventing HIV transmission. Less than one in ten vulnerable children in sub-Saharan Africa are reached by basic support services. Stigma and discrimination are still pervasive, and remain a serious obstacle to the success of HIV/AIDS intervention programmes. The Secretary-General added that “comprehensive AIDS treatment and care involves more than antiretrovirals, encompassing the treatment of opportunistic infections, proper food and nutrition, psychosocial care and other essential health and social services…While developing countries should do more to finance the response to HIV, the world must look primarily to international donors to close the looming resource gap”.
The 2006 Meeting was the first in which a person living with HIV/AIDS (PLWH) was invited to address an UNGASS meeting. This has opened a much needed channel of communication between global policy makers and those for whom the policy is being devised. The 2006 meeting recommitted itself to implement fully the 2001 Declaration of Commitment, the Millenium Development Goals, and other internationally agreed goals and objectives. Another first was the resolution to integrate food and nutritional support in the response to HIV/AIDS, with the Global Fund in future to include funding for nutrition in ART roll-out funding. The meeting urged the Global Fund and other international donors to provide additional resources to low- and middle-income countries for the strengthening of HIV/AIDS programs and health and social service systems, and for addressing gaps in resources.
Mental Health and HIV/AIDS in low-income countries
Many factors contribute to an increased mental health burden in low-income countries. Higher rates of morbidity and mortality from a range of infectious diseases and environmental hazards contribute to a raised prevalence of mental and developmental disorders, as do poverty, the plight of women, and the difficult circumstances which children have to endure. Ignorance and stigma regarding mental disorders, compounded by major treatment gaps, also contribute significantly to the burden. The implication is that large numbers of children, adolescents and adults, rather than only a small severely affected proportion, are suffering from or at risk for mental health problems in these countries. Furthermore, indications are that the burden of mental health in low-income countries is on the increase.
HIV infection induces a range of serious mental disorders. Even post-HAART, PLWH continue to remain at risk for common mental disorders and mild cognitive impairment. Individuals with pre-existing mental or personality disorders have increased vulnerability to HIV infection, and may present major challenges in the areas of voluntary counseling and testing, high-risk behaviour, adherence to antiretroviral treatment, and parenting capacity. HIV/AIDS undermines parenting functions and the quality of the parent-child relationship, especially when mothers are infected. HIV/AIDS also leads to profound psychosocial adversity for infected and affected children, increasing the risk of mental and developmental disorders.
Evidence is accumulating that mental disorders and other psychosocial stressors decrease the CD4 count and increase the viral load, even in those enrolled in HAART programs. Interventions to treat mental disorders and manage psychosocial stressors have been found to reverse these effects. Mental health interventions with persons living with AIDS who do not have mental disorders appear to exert beneficial effects in a number of settings: for instance, interventions to improve coping skills are associated with positive effects on CD4 counts and viral loads; and interventions to assist with disclosure issues improve adherence, as do interventions to improve patient-physician communication and interactions.
In summary, the existing mental health burden in low-income countries is significantly raised and on the increase. HIV/AIDS is associated with an elevated risk of mental disorder in infected individuals and their children, which is likely to persist post-HAART and post-Psychosocial Support for at least another generation. Mental disorder is associated with an increased risk both of contracting HIV infection, and of undermining the body’s response to the infection, even in the presence of antiretrovirals. The implication is that mental health, like stigma or food and nutrition, is a significant mediator in the success of HAART and psychosocial support programs in low-income countries. Their citizens’ lack of access to mental health services is of grave concern and import.
Mental health and the global HIV/AIDS response
UNAIDS and its partners have recognized the circular relationship between HIV/AIDS and social and other disadvantage, such as poverty, gender inequality, and poor nutrition. The last few years have seen increasing calls to improve the efficacy of HAART and psychosocial support in low-income countries by increasing multisectoral collaboration, strengthening linkages with national development plans and strategies such as poverty eradication strategies, embedding funding for food and nutritional support in HAART budgets, and mainstreaming HIV/AIDS interventions in all health and social service programs, including disaster programs. There are calls for psychosocial support programs to be integrated with paediatric HAART, home-based care and all the childhood programs with which HAART is being integrated, including nutrition. Psychosocial support programs are moving away from discriminating between orphans and children made vulnerable by HIV/AIDS, and the many other vulnerable children in developing countries. Added to these developments, have been the recent calls by the WHO 3 by 5 Mental Health working group for the integration of mental health into HIV/AIDS interventions in low-income countries.
Currently, mental health is not integrated with HAART programs, nor has this been recommended in any of the major international HIV/AIDS declarations to date. Mental health is not specifically identified as a matter for concern in any of the HIV/AIDS global policy documents or funding strategies. Historically, psychosocial support programs have focused on the social needs and coping capacity of vulnerable children and their carers, rather than on the identification of those at risk for mental and developmental disorders, and their prevention and treatment. In the light of the mutually reinforcing relationship between mental health problems and HIV/AIDS, WFMH urges that mental health be integrated into all HIV/AIDS interventions in low-income countries. Researching, costing, implementing and evaluating effective and sustainable models of integration are a priority. Core funding for the development and/or strengthening of mental health services should be incorporated into global funding initiatives for HAART, psychosocial support and other HIV/AIDS programs.
The WHO 3 by 5 Mental Health working group has developed a number of training materials but mental health care resources in developing countries are severely limiting the implementation of training programs. Until all the essential elements of mental health care are present in low-income countries, such as promotion, prevention, care and rehabilitation, as well as sufficient trained staff and access to essential psychotropic medication, there is a likelihood that this important initiative will deliver too little too late. The integration of mental health into HIV/AIDS in low-income countries will require urgent strengthening of their mental health programs. The WHO has recommended that the development and implementation of an adequately funded National Mental Health Policy and Plan is the most effective way of ensuring provision of appropriate mental health care. National Mental Health and HIV/AIDS Plans need to be coordinated and integrated.
Without integration the effectiveness of HAART and psychosocial support programs in low-income countries will be seriously undermined, and the quality of life of survivors of HIV/AIDS and their families significantly reduced. Only recognition of the adverse impact of mental health problems on the AIDS pandemic and an urgent response by UNAIDS in collaboration with its intergovernmental and nongovernmental partners, and member countries can avert this outcome. A first step towards the global integration of mental health into HIV/AIDS interventions would be the integration of mental health into the policy making structures of all international, regional and national bodies responsible for interventions.
WFMH recognizes that access to ART and preventive programs are fundamental to stopping the pandemic, and also have a major impact on the mental health of those infected or affected by HIV/AIDS. However WFMH wishes to re-iterate that the mental and physical elements and consequences of HIV/AIDS are interrelated, and that a large proportion of the population in many low-income countries is at high risk for mental health problems. Mental health is being insufficiently addressed in current HIV/AIDS interventions in low-income countries. Given the concentration of the epidemic in those countries and their rising burden of mental health, the World Federation for Mental Health calls upon the international community to advocate for
the Board of Directors