Mental health as a barrier to HIV testing and care

Pathways to HIV testing and care in Goa, India: exploring psychosocial barriers and facilitators using mixed methods.

Mayston R, Lazarus A, Patel V, Abas M, Korgaonkar P, Paranjape R, Rodrigues S, Prince M. BMC Public Health. 2016 Aug 11;16(1):765. doi: 10.1186/s12889-016-3456-4.

Background: Despite recognition of the importance of timely presentation to HIV care, research on pathways to care is lacking. The adverse impact of depression upon adherence to antiretroviral therapy is established. There is emerging evidence to suggest depression may inhibit initial engagement with care. However, the effect of depression and other psychosocial factors upon the pathway to care is unknown.

Methods: We used mixed methods to explore pathways to care of people accessing testing and treatment in Goa, India. Questionnaires including measures of common mental disorder, hazardous alcohol use, cognition and assessment of pathways to care (motivations for testing, time since they were first aware of this reason for testing, whether they had been advised to test, who had given this advice, time elapsed since this advice was given) were administered to 1934 participants at the time of HIV testing. Qualitative interviews were carried out with 15 study participants who attended the antiretroviral therapy treatment centre. Interview topic guides were designed to elicit responses that discussed barriers and facilitators of accessing testing and care.

Results: Pathways were often long and complex. Quantitative findings revealed that Common Mental Disorder was associated with delayed testing when advised by a Doctor (the most common pathway to testing) (AOR = 6.18, 2.16-17.70). Qualitative results showed that triggers for testing (symptoms believed to be due to HIV, and for women, illness or death of their husband) suggested that poor health, rather than awareness of risk was a key stimulus for testing. The period immediately before and after diagnosis was characterised by distress and fear. Stigma was a prominent backdrop to narratives. However, once participants had made contact with care and support (HIV services and non-governmental organisations), these systems were often effective in alleviating fear and promoting confidence in treatment and self-efficacy.

Conclusion: The effectiveness of formal and informal systems of support around the time of diagnosis in supporting people with mental disorder is unclear. Ways of enhancing these systems should be explored, with the aim of achieving timely presentation at HIV care for all those diagnosed with the disease.

Abstract [1]  Full-text [free] access [2] 

Editor’s notes: Late presentation to HIV care is associated with poorer outcomes for individuals living with HIV (increased risk of morbidity and death) and for treatment programmes (increased costs). The focus of this mixed methods study was to improve understanding of the impact of common mental disorders, hazardous alcohol use and cognitive impairment on accessing HIV testing and care in India. Although the investigators report that common mental disorders increased the possibility of delayed testing, internalised stigma and fear of discrimination was a common theme in the qualitative narratives. Stigma is associated with poorer mental health, including emotional distress, depression and reduced psychological functioning. It has also been linked to intermediate health outcomes such as seeking healthcare and adherence to antiretroviral therapy. These results reinforce the need to develop and evaluate programmes to address HIV-associated stigma so that people living with HIV can access care and benefit from treatment. However, development of appropriate programmes requires a better understanding of the complexities of HIV-associated stigma. These include the relationship between stigma, depression and social support and the intersection of HIV-associated stigma and other types of stigma experienced by people living with HIV, such as homophobia and gender discrimination.

Stigma and social exclusion [4]
Asia [5]
India [6]
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