Health Facility

This study was conducted to examine the linkages between mental health and socio-economic outcomes in poor, conflict-affected countries. Data was collected from a survey of 5,599 conducted country-wide in Burundi. This study proposed that poor mental health diminishes people’s participation in work and investment in their children’s education through dysfunction resulting from psychiatric trauma and depression. Economic theory holds that investment in human capital, such as in education, will depend in part on expectations about the return on the investment. Combining the psychological and economic theory with findings of this study, it is suggested that poor mental health is one of the causes of low enrollment of children in primary education. Hence, these results suggest that mental health programs could be one of the means for promoting participation in labor and increased investments in education.

The TIP provides information about new developments in the co-occurring substance use and mental disorders and captures the state-of-the-art in the treatment of people with co-occurring disorders. The TIP focuses on what the substance abuse treatment clinician needs to know and provides that information in an accessible manner.

This editorial consists of relevant articles that aims to support professionals and volunteers caring for or treating mentally ill people.

This study illustrates how a mental health problem develops after an HIV diagnosis. As findings of the study indicate, people with HIV may experience a wide range of mental health problems, which not only affect quality of life but also negatively affect health-seeking behaviour, adherence, retention in care, transmission risk and clinical health. Studies also show a high prevalence of psychiatric disorders in people with HIV, most commonly depression, anxiety and substance misuse. Furthermore, when identified, depression can be managed by physicians or clinical officers, but health care workers need to be aware of the potential for interactions between many drugs used in psychiatric treatment and antiretroviral drugs.

Epidemiological studies in the United States estimate HIV seroprevalence rates ranging between 4% and 23% for serious mentally ill adults (SMIA; i.e., schizophrenia, bipolar disorder, and other chronic disorders with psychotic features), with substantially greater estimates for risky sexual behaviors. Among the most consistent factors linked to HIV risk in non-SMIA populations is a history of emotional, physical, or sexual abuse. The current study examined the intersection of abuse history and HIV sexual risk behavior in SMIAs. A cross-sectional interview revealed a high prevalence of alcohol and other drugs problems, as well as a history of emotional, physical, or sexual abuse in 75% of the participants. Compared to nonabused counterparts, those with a history of abuse reported significantly greater: (a) lifetime and current psychiatric symptoms, (b) recent unprotected sexual intercourse, and (c) crack cocaine, heroin, and marijuana use. These results underscore the need for HIV prevention efforts targeted to SMIAs and the critical importance of addressing abuse history in interventions with this underserved population.

African Based Resources on Mental Health and HIV/AIDS

HIV testing in mental health settings.

The relationship between TB/HIV co-infection and common mental disorders (CMD) has been scarcely investigated. This study examined the occurrence of CMD in TB/HIV co-infected and non-co-infected HIV patients in Ethiopia. Results indicated that ndividuals who had no source of income and day labourers were more likely to have CMD as compared to individuals who had a source of income and government employees respectively. Patients who perceived stigma and who rate their general health as "poor" had significantly greater risk of CMD than individuals who did not perceive stigma or who perceived their general health to be "good". Therefore, TB/HIV control programs should develop guidelines to screen and treat CMD among TB/HIV co-infected patients. Screening programs should focus on individuals with no source of income, jobless people and day labourers.

Mental health related risk factor for non-adherence to highly active anti-retroviral therapy (HAART) is a critical issue that needs to be address for the effective treatment. This study aimed to determine whether psychological distress is a risk factor for non-adherence to HAART among HIV positive individuals. It was found that psychological distress and living in isolation were significantly associated with non-adherence to HAART. Furthermore, among HIV positive individuals who were receiving additional treatment for a mental disorder, psychological distress was not significantly associated with non-adherence to HAART. Therefore, it was found that regular screening and management of psychological distress may prevent further complications in HIV positive individuals in Uganda.

The aim of the study was to study factors related to anxiety, depression, and suicidal ideation among HIV-seropositive heterosexuals soon after being tested for their HIV status for the first time. Anxiety, depression, and suicidal ideation were assessed among 51 HIV-seropositive heterosexual men and women with various stages of HIV infection. Psychosocial variables such as quality of family relationships and substance use and sociodemographic details such as gender, income, education, and residence were studied for their association with psychiatric morbidity. Illness details studied for their association with psychiatric morbidity included stage of HIV infection, spouse’s HIV status, presence of physical illness, and pain. Depression was present in 40% and anxiety in 36% of the sample. Serious suicidal intent was seen in 14%. Results also indicated that presence of pain, concurrent alcohol abuse, poor family relations, and presence of AIDS in the spouse were significant factors associated with depression, anxiety, and suicidal ideation.

This study evaluated the effects of information and education intervention on the knowledge and attitude of primary health care workers towards mental disorders. The result of this study suggests that information and education intervention improved health workers knowledge of mental illness causation and attitude towards the mentally ill in the study community. The simple intervention could be replicated in other rural communities in Nigeria and Africa to aid the development of community mental health services.

Highly active antiretroviral therapy (HAART) has had a dramatic impact not only on the natural history of HIV but also on the psychosocial and health care needs of HIV positive people. HAART has brought with it a new range of psychosocial issues for HIV-positive people to confront and psychosocial needs for service providers to meet. In an attempt to understand better the social and psychological consequences of this dramatically changed situation, the British HIV Association (BHIVA) Social and Behavioral Sciences (SBS) Subcommittee commissioned this scoping exercise.

The 2008 report on the Global AIDS Epidemic is a report targeting universal access to HIV prevention, treatment, care, and support. The current juncture provides an opportunity to assess the HIV response and to understand what must be done to ensure that nations are on course to achieve the HIV commitments they have made.

UNAIDS Best Practices Collection

This study surveys specifically adolescents in southern Malawi on their experience of the impacts of living with HIV or AIDS on one’s mental health. At the same time, the study explores the link between mental health problems and subsequent HIV-risk behaviour. Short texts relating everyday scenarios that depicted symptoms of three mental health problems (i.e. depression, anxiety and HIV-related brain impairment) formed the basis of in-depth discussions in 12 existing groups of secondary school students, orphans and vulnerable children, teenage mothers, and out-of school youths, in both rural and urban settings. The responses show that these young people recognised the mental health sequelae of HIV/AIDS as impacting upon many aspects of one’s life. More importantly, they identified a number of locally derived community interventions, which if supported by statutory health and education services, can significantly ameliorate their situations. The findings provide avenues for practical integration of mental health provision within HIV prevention, education and care initiatives.

This paper reviews twenty seven published quantitative research on the mental health of HIV-infected adults in Africa. Most studies found that about half of HIV-infected adults sampled had some form of psychiatric disorder, with depression the most common individual problem. People living with HIV or AIDS (PLHIV) tended to have more mental health problems than non-HIV-infected individuals, with those experiencing less problems less likely to be poor and more likely to be employed, educated and receiving antiretroviral treatment (ART). Being female, experiencing poor health, receiving poor-quality health services, and a lack of material and emotional support from family and friends were associated with greater psychiatric morbidity. Nonetheless, priorities for future research should include replicating findings regarding common mental health problems among PLHIV, important issues among HIV-infected women, and the longer-term mental health needs of those on ART. Research is also needed into predictors of mental health outcomes and factors associated with adherence to ART, which can be targeted in interventions.

The study aims to test the effectiveness of collaborative HIV Adolescent Mental Health Program among black South Africans, in youths (ages 9-13) and their families in KwaZulu-Natal, South Africa. The CHAMPSA intervention targeted HIV risk behaviors by strengthening family relationship processes as well as targeting peer influences by enhancing social problem solving and peer negotiation skills for youths. Findings indicated that among caregivers, significant intervention group differences were revealed regarding HIV transmission knowledge, less stigma toward HIV-infected people, caregiver monitoring—family rules, caregiver communication comfort, caregiver communication frequency and social networks. Among youths, data revealed that control and experimental groups were significantly different for children in AIDS transmission knowledge and less stigma toward HIV-infected people. Therefore, CHAMPSA enhances a significant number individual, family and community protective factors that can help youths avoid risky behaviors leading to HIV-positive status.

Prior to antiretroviral therapy (ART), perceived risk for developing AIDS and AIDS-related life events (e.g., diagnosis of an AIDS-related complex) were important determinants of suicide intent. The burdens of coping with advanced HIV and the threat of death may partially explain the markedly elevated suicide rate among HIV-positive persons during this period. Given that the introduction of ART has led to substantial improvements in HIV-related health outcomes, Keiser and colleagues examined whether the suicide rate declined over time in the Swiss HIV Cohort Study compared to the general Swiss population. It was proposed that stress and coping model of suicide risk in which vulnerability and resilience factors modulate psychological responses to precipitating events that increase suicide risk. Their findings indicate that the suicide rate among HIV-positive persons declined in the ART era, and this appeared to be due partially to improvements in health status. However, the suicide rate remains more than three times higher among HIV-positive persons than in the general population. This finding highlights the need for an integrative conceptual model to inform clinical intervention and research that addresses suicide risk in HIV-positive persons.

To determine the health-seeking behavior of mentally ill patients in Enugu, Nigeria. A consecutive recruitment of patients receiving treatment at the neuropsychiatric hospital in Enugu was done. Misconceptions regarding the cause of mental illness still abound among mentally ill patients in Nigeria. Consequently, psychiatric consultation is not usually initially employed, especially in rural areas. As a result, community health education aimed at changing misconceptions, and the integration of mental health services into primary health care services, is advocated.

As the roll-out of antiretrovirals (ARVs) to people living with HIV/AIDS (PLWHA) continues to increase in South Africa, the need to integrate mental health services into HIV care also increases. In this editorial, it is argued that the role of mental health in ARV programmes is central. The prevalence of mental disorders in PLWHA is higher than in the general population, and the impact of these conditions is substantial. Screening tools for mental disorders are both available and feasible. Hence, these should be incorporated into routine ARV care, with support from dedicated HIV mental health services.

This study was examined the knowledge, attitude and beliefs about causes, manifestations and treatment of epilepsy among adults in a northern Nigerian urban community. The low level of knowledge and misconceptions demonstrates the need for community educational programmes aimed at demystifying epilepsy with a view to allaying fears and mistrust about the disease as well as lessen stigmatization toward epileptics.

This report presents findings from a multi-community survey of local-level responses to HIV/AIDS in three South African communities- Vosloorus, Obanjeni, and Grahamstown. The given research was initiated to investigate the scope and scale of community responses to HIV/AIDS as part of a process of better understanding the possibilities for linking organic local level responses into a supported, sustainable, co-ordinate and ultimately integrated system of responses that combines the efforts of state and community.

This document is a technical brief conducted by USAID in collaboration with AIDSTAR-One. The brief provides a framework to integrate mental health into the care and support of PLWH in resource limited setting. The study adopts a multi-level, three tiered, comprehensive approach of mental health services that includes: treatment of mental health disorder at the primary care level, psychosocial support for at risk groups and community based interventions for promotion of positive mental health in the general population. The study also discusses on some of the challenges in addressing mental health issues in HIV/AIDS resource limited countries which includes; disproportionate burden of HIV/AIDS among women and the resulting psychosocial need for women and children, role of sigma and human resource need. Given the complexity of mental health and psychosocial issues in HIV/AIDS in resource-limited countries, the study recommends that it is necessary to move beyond the traditional model of mental health care and developing culturally appropriate and responsive care and support for People living and affected by HIV.

In recent years, traditional health practice has been mainstreamed in South Africa. Due to the extent of integration of mental health in the legal definition of traditional health practice, promulgation of this act has significant implications for mental health care delivery. This study explored the documented interface of traditional health practice with mental health care in South Africa over the past almost 50 years. The documentation on the interface between the two parallel systems contribute to establish a context against which the promulgation of the legislation to formally integrate and regulate African traditional health practice in South Africa can be considered. South African policy makers may now have ensured that a multi-faceted context for health and mental health care delivery has come to pass. However, to health administrators, the inclusion of traditional healers into the formal public health system and mental health may still prove to be too costly to implement.

This study examined the relationships among perceived social support, coping strategies and antiretroviral medication adherence in a sample of 224 rural women with HIV disease, recruited from community-based HIV/AIDS organizations serving rural areas of three states in southeastern United States. Findings of the study demonstrated that of the 224 women in the sample receiving combination antiretroviral therapy, 133 (59.38%) were non-adherent to their drug regimens at least once during the past month. Findings also indicate that social support and coping strategies influence adherence to antiretroviral drug regimens among rural women with HIV disease. It is not mere availability of social support, but the satisfaction of the available support which is important for better adherence. Coping by spiritual activities and focusing on the present mediated the effect of social support on medication adherence. Satisfaction with available support and coping by managing HIV disease were the best positive predictors of medication adherence. On the contrary, the number of children was a negative predictor of medication adherence.

This study examined the relationship between the experience of various HIV-related events (receiving the diagnosis, receiving treatment, experiencing physical symptoms, self-disclosing HIV positive status, and witnessing HIV-related death) and posttraumatic stress symptoms in a sample of 100 gay men living with HIV. Self-reported data revealed that 65% met criteria for having experienced a traumatic event. The experience of shame, humiliation, or guilt during an event was measured but not found to be a significant indicator of having been traumatized. The results also indicated that receiving medical treatment, experiencing physical symptoms, and witnessing HIV-related death were most associated with HIV-related PTSD symptoms. Given that multiple HIV-related events are potentially traumatic, the screening, assessment and treatment for HIV-related PTSD may need to be considered by HIV services.

A study was conducted in eight cities of Shandong Province, China to examine the seroprevalence of HIV and syphilis infection, and the mental health of "money boys”. The study revealed that factors associated with the infection were having sex with women in the past 6 months and suffering STD-like symptoms. There were 77.2% participants engaged in such an occupation for economic survival. The prevalence of anxiety and depression among money boys also revealed significant. Heterosexual money boys were more likely to suffer from such mental symptoms. This study revealed the urgent need for interventions for HIV/AIDS control with mental counseling targeting this vulnerable population.

People living with HIV face a new situation since the arrival of the antiretroviral treatments. HIV has become a long-term condition, which not only affects physical health, but also causes psychological and social problems because of stigma and discrimination. These challenges present many decisions and dilemmas for people living with HIV. The aim of this study was to examine the psychosocial decision needs of people living with HIV. The results show that people living with HIV face three key decisions: (i) whether or not to disclose their diagnosis to others; (ii) decisions about adherence to treatments; and (iii) decisions about sexual activity and desires about parenthood. Problems associated with these decisions often result in isolation and mental illness such as depression and anxiety, lack of access to social support, and refusal to seek treatment. As this is key to address HIV and public impact, it is a requirement to develop interventions to support the psychosocial needs of people living with HIV, to accurately reflect the views and needs of the target users.

Drug abuse has serious consequences for the wellbeing of persons with HIV/AIDS. This study examines and compares client characteristics that predicted engagement (defined as attendance at two or more sessions) in a family intervention and a group intervention aimed at preventing relapse and improving medication adherence among African American HIV+ women in drug abuse recovery. Findings indicated that fewer physical and mental symptoms (malaise), living independently, living with children, and readiness to change were associated with engagement across the two interventions. Therefore, results from this study can be used to inform outreach and engagement approaches for women dually affected by drug abuse and HIV/AIDS.

The feasibility and effectiveness of a hospital-based exercise-training program followed by a home-based program for improving fitness, strength, and changes in body composition in children and adolescents with HIV were evaluated. Subjects participated in nonrandomized 24-session, hospital supervised exercise training program followed by an 314 unsupervised home-based maintenance program. Outcome measurements included muscular strength/endurance, flexibility, relative peak VO(2), body composition, and lipids. Seventeen subjects (eight females) with a median age of 15.0 years (range: 6.0-22.6) and BMI z-score of 0.61 (range: -1.70-2.57) at entry completed the intervention. After 24 training sessions, the median increases in muscular strength were between 8% and 50%, depending on muscle group. The median increases in muscle endurance, relative peak VO(2), and lean body mass were 38.7% (95% CI: 12.5-94.7; p = 0.006), 3.0 ml/kg/min (95% CI: 1.5-6.0; p < 0.001), and 4.5% (95% CI: 2.4-6.6; p < 0.001), respectively. Twelve children completed the home-based maintenance program. Median changes in these outcomes between completion of the hospital-based intervention and a follow-up after completion of the home-based program were near zero. No adverse events occurred during the intervention. A supervised hospital-based fitness program is feasible, safe, and effective for improving general fitness and strength as well as lean body mass in children with HIV.

BACKGROUND: Iron-related genes and iron status may independently contribute to variable HIV outcomes. The nature of the biologically plausible gene-nutrient interaction remains unknown. OBJECTIVES: The objectives were to investigate whether iron-related genotypes and clinically abnormal iron status independently predict mortality in HIV and whether a gene-nutrient interaction exists. DESIGN: Baseline plasma, DNA, and clinical data were obtained from 1362 HIV-seropositive Gambian adults followed for 11.5 y to ascertain all-cause mortality. Iron status was estimated on the basis of plasma iron, soluble transferrin receptor (sTfR), ferritin, transferrin, transferrin index, and log(sTfR/ferritin). One haptoglobin (HP) and 5 SLC11A1 (NRAMP1) polymorphisms were genotyped. RESULTS: SLC11A1-SLC3 and CAAA polymorphisms were the best independent genetic predictors of mortality [adjusted mortality rate ratio (95% CI)]: SLC3:G/C = 0.59 (95% CI: 0.45, 0.85), CAAA:del/ins = 1.51 (95% CI: 1.10, 2.07). In an adjusted model that included all polymorphisms, SLC1:199/199, SLC1:other/other, SLC6a:A/A, and CAAA:del/ins were associated with significantly greater mortality, whereas Hp 2-1 and SLC3:G/C were protective. In unadjusted analyses, all biomarker concentrations were significantly associated with mortality. In an extension of previous findings, both low and elevated iron states were associated with mortality, but the nature of the risk was variable, with linear, inversely linear, and U-shaped associations depending on the biomarker. Mortality was significantly lower in HIV-2 than in HIV-1 infection in the presence of abnormal (low or elevated) iron status. A gene-iron interaction was detected (likelihood-ratio test P = 0.018); however, subject numbers restricted category-specific interpretation. CONCLUSIONS: Iron-related genes, iron status, and their interaction predict mortality in HIV. These findings illustrate the complexity and uncertainty surrounding best practice for managing abnormal iron status and anemia during HIV infection and in regions with a high risk of infection.

This study predicted that is that mental health service delivery results in improvement in terms of psychopathology and disability in comparison to a control group. The paper describes a treatment outcome study on mental health interventions provided by TPO Burundi. The study uses a naturalistic effectiveness design with high external validity enabling the assessment of the public mental health benefits of the interventions. The aims of this paper are to assess the effectiveness of individual psychosocial and psychiatric care and to estimate the costs and financial benefits of these interventions.

This is a report on the assessment of the mental health system in Guyana using the World Health Organization - Assessment Instrument for Mental Health Systems (WHO-AIMS). This will enable Guyana to develop information-based mental health plans with clear base-line information and targets. It will also be useful to monitor progress in implementing reform policies, providing community services, and involving users, families and other stakeholders in mental health promotion, prevention, care and rehabilitation.

IV-infected drug users have increased age-matched morbidity and mortality compared with HIV-infected people who do not use drugs. Substance-use disorders negatively affect the health of HIV-infected drug users, who also have frequent medical and psychiatric comorbidities that complicate HIV treatment and prevention. Evidence-based treatments are available for the management of substance-use disorders, mental illness, HIV and other infectious complications such as viral hepatitis and tuberculosis, and many non-HIV-associated comorbidities. Tuberculosis co-infection in HIV-infected drug users, including disease caused by drug-resistant strains, is acquired and transmitted as a consequence of inadequate prescription of antiretroviral therapy, poor adherence, and repeated interfaces with congregate settings such as prisons. Medication-assisted therapies provide the strongest evidence for HIV treatment and prevention efforts, yet are often not available where they are needed most. Antiretroviral therapy, when prescribed and adherence is at an optimum, improves health-related outcomes for HIV infection and many of its comorbidities, including tuberculosis, viral hepatitis, and renal and cardiovascular disease. Simultaneous clinical management of multiple comorbidities in HIV-infected drug users might result in complex pharmacokinetic drug interactions that must be adequately addressed. Moreover, interventions to improve adherence to treatment, including integration of health services delivery, are needed. Multifaceted, interdisciplinary approaches are urgently needed to achieve parity in health outcomes in HIV-infected drug users.

A more prominent role is needed for mental health interventions in global HIV/AIDS initiatives -- such as the World Health Organization'3 by 5' Initiative. Significant numbers of infected people have, or develop, mental health problems, and this often adversely impacts on HIV/AIDS treatment and adherence. Integrating psychiatric and psychosocial interventions should benefit both the mental and the physical health of people living with HIV/AIDS.

This WHO strategy aims to set out in clear detail how life-long antiretroviral treatment can be provided to 3 million people living with HIV/AIDS in poor countries by the end of 2005 with core principles including urgency, equity and sustainability.

This is a report of the assessment of the mental health system in Nigeria using the World Health Organization - Assessment Instrument for Mental Health Systems (WHO-AIMS). This will enable Guyana to develop information-based mental health plans with clear base-line information and targets. It will also be useful to monitor progress in implementing reform policies, providing community services, and involving users, families and other stakeholders in mental health promotion, prevention, care and rehabilitation.

The expansion of AIDS treatment initiatives in resource-poor settings provides an opportunity for integrating mental health care into these programs. This systematic review of the literature on HIV and mental illness in developing countries examines the mental health risk factors for HIV, mental health consequences of HIV, psychosocial interventions of relevance for HIV-infected and affected populations, and highlights the relevance of these data for HIV care and treatment programs. We reviewed seven studies that measured the prevalence of HIV infection among clinic and hospital-based populations of people with mental illness or assessed sexual risk behavior in these populations; 30 studies that described the mental health consequences of HIV infection; and two reports of psychosocial interventions. The review demonstrates the need for methodologically sound studies of mental health throughout the course of HIV, including factors that support good mental health, and interventions that employ identified variables (e.g. coping, family support) for efficacy in reducing symptoms of mental illness. Promising intervention findings should encourage investigators to begin to study the implementation of these interventions in HIV service settings.

This is a randomized control trial aiming to assess the long-term effectiveness of therapy over a subsequent 6-month period. The study comparing group interpersonal psychotherapy with treatment as usual among rural Ugandans meeting symptom and functional impartment criteria DSM-IV major depressive disorder or sub-threshold disorder showed evidence of effectiveness immediately following the intervention. Results indicated that participation in a16 week group interpersonal psychotherapy intervention continued to confer a substantial mental health benefit 6 months after conclusion oft he formal intervention.

Home based care (HBC) has been an important component of the response to the AIDS epidemic in Africa, and particularly so before antiretroviral therapy (ART) became available. One way to investigate if there is a decreased need for HBC due to the availability of ART is to assess the changing need for comprehensive HBC as an ART programme becomes available. Since the availability of ART in the local health facilities and despite strenuous efforts to persuade people to seek HIV testing and ART, in practice barriers existed and half the eligible HBC patients did not have access to ART. This is one reason why the clinical need for HBC services had not changed much. In terms of quantity of care, the number of new patients seeking HBC reduced by 8% a year. In terms of content of care, while there had been a marginal increase in self care the severity of illness had not changed and the survival of a significant proportion of patients generated the need for repeat visits, which increased by 9% a year. In conclusion, although the content has changed, the need for HBC has not diminished despite the availability of ART.

Management of Pain using the WHO analgesic ladder

Managing side effects of in patients taking morphone

Care-seeking behaviors of people living with HIV or AIDS could sometimes result in suboptimal quality of live. This paper examines the role of stigma on care-seeking behavior of people living HIV or AIDS in sub-Saharan Africa. Studies show a correlation between care-seeking behavior and beliefs about pathways of HIV infection and people infected with HIV, social reactions, coping strategies, knowledge of HIV and AIDS, and self-efficacy in finding care and treatment in addition to coping with the disease. The findings indicate that poverty, gender, age, religion and policy are moderating variables. The Precede- Proceed model was adapted to build an explanatory model of healthcare-seeking behaviour among PLHIV and particularly to explore the role of stigma in the non-utilization of healthcare institutions.

Antiretroviral regimens for HIV-infected patients require strict adherence. In the past, studies have shown untreated depression to be associated with medication nonadherence. This study proposed to evaluate the effect of antidepressant treatment (ADT) on antiretroviral adherence. Antiretroviral adherence improved over a 6-month period for adherent, nonadherent, and nonprescribed ADT groups; however, the mean pre– versus post–6-month change in antiretroviral adherence was significantly greater for those prescribed antidepressants. The findings indicated that depression was common, and antiretroviral adherence was higher for depressed patients prescribed and adherent to ADT compared with those neither prescribed nor adherent to ADT. Therefore, attention to diagnosis and treatment of depressive disorders in this population may improve antiretroviral adherence and ultimate survival.

Co-occurring mental health and substance use disorders (COD) are the norm rather than the exception. It is therefore critical that performance measures are developed to assess the quality of care for individuals with COD irrespective of whether they seek care in mental health systems or substance abuse systems or both. Policymakers need to work with all stakeholders to establish a concrete agenda for developing, piloting and implementing performance measures that include COD. Future research could begin to consider strategies that increase the ability to use administrative coding in mental health and substance use disorder systems to efficiently capture quality relevant clinical data.

This paper reviews available literature on PMTCT programmatic models that have taken a broader or family-centred approach. It examines findings and barriers to the delivery of family-centred PMTCT and identify a number of promising new directions that may achieve more holistic services for children and families. Results indicated that the most common aspects of family-centred care incorporated by PMTCT studies and programme models included counselling, testing, and provision of antiretroviral treatment for infected pregnant women and their partners. Antiretroviral therapy was also commonly extended to other infected family members. Efforts to involve fathers in family-based PMTCT counselling, infant feeding counselling, and general decision making were less common, though promising. Despite barriers, numerous opportunities exist to expand PMTCT services to address the health needs of the entire family. Furthermore, findings reveal that family-centred prevention measures can be effectively integrated within programmes. However, additional research is needed in order to more thoroughly evaluate their impact on PMTCT, as well as on broader family health outcomes.

This document is the WHO guidance to countries on how to organize services for mental health using the optimal mix of services pyramid framework. The framework categorizes mental health services in ascending order namely; primary care services, community mental health services and psychiatric services based in general hospitals and lastly specialist and long stay mental health services. The study shows that mental health hospital and specialist services present the highest cost, yet are the least frequently needed service in contrast to self-care or informal community care, which has a high frequency of need and can be provided at a low cost. Based on the Optimal Mix of Services Pyramid, WHO makes the following recommendations; limit mental hospitals, build community mental health services, develop mental health services in general hospitals, integrate MH services into primary health care, build informal community mental health services and promote self-care.

The document presents a comprehensive definition of mental health and calls for the integration of mental health in the health promotion arena. In this context, the papers indicates, public health goals for prevention and health promotion are just as applicable in mental health as they are in any physical disorder. To adequately and effectively address mental health issues, cost effective strategy in promoting mental health must involve policy framework and advocacy as well as addressing the needs of vulnerable groups in society such as women, children, poor, migrants, people affected by disaster and wars. To implement these effective interventions, governments need to adopt a mental health framework as used to advance other areas of health and socio-economic development, and thereby engage all relevant sectors to support and evaluate activities designed to promote mental health.

This study identifies three sets of structural barriers to ART adherence that are salient in Southern Africa: poverty-related, institutional, and political and cultural. Examples of poverty-related barriers are competing demands in the context of resource-constrained settings, the lack of transport infrastructure, food insecurity, the role of disability grants and poor social support. Examples of institutional factors are logistical barriers, overburdened health care facilities, and limited access to mental health services. Examples of political and cultural barriers are controversies in the provision of treatment for AIDS, traditional beliefs about HIV and AIDS, poor health literacy and gender inequalities. In forging a way forward, the study identifies ways in which individuals, communities and health care systems may overcome some of these structural barriers and provides recommendations for further research on structural barriers to ART adherence. In all likelihood, enhancing adherence to ART requires the efforts of a variety of disciplines, including public health, psychology, anthropology, sociology and medicine.

Objective: To study factors associated with the probability of retention in antiretroviral therapy (ART) programmes in West Africa.

Methods: The International epidemiologic Databases to Evaluate AIDS (IeDEA) in West Africa is a prospective, operational, observational cohort study based on collaboration between 11 cohorts of HIV-infected adult patients in Benin, Coˆ te d’Ivoire, Gambia, Mali and Senegal. All patients aged 16 and older at ART initiation, with documented gender and date of ART initiation, were included. For those with at least 1 day of follow-up, Kaplan–Meier method and Weibull regression model were used to estimate the 12-month probability of retention in care and the associated factors.

Results: In this data merger, 14 352 patients (61% female) on ART were included. Median age was 37 (interquartile range (IQR): 31–44 years) and median CD4 count at baseline was 131 cells ⁄mm3 (IQR: 48–221 cells ⁄mm3). The first-line regimen was NNRTI-based for 78% of patients, protease inhibitorbased for 17%, and three NRTIs for 3%. The probability of retention was 0.90 [95% confidence interval (CI): 0.89–0.90] at 3 months, 0.84 (95% CI: 0.83–0.85) at 6 months and 0.76 (95% CI: 0.75– 0.77) at 12 months. The probability of retention in care was lower in patients with baseline CD4 count <50 cells ⁄mm3 [adjusted hazard ratio (aHR) = 1.37; 95% CI: 1.27–1.49; P < 0.0001] (reference CD4 > 200 cells ⁄mm3, in men (aHR = 1.17; 95% CI: 1.10–1.24; P = 0.0002), in younger patients (<30 years) (aHR = 1.10; 95% CI: 1.03–1.19; P = 0.01) and in patients with low haemoglobinaemia <8 g ⁄ dl (aHR = 1.33; 95% CI: 1.21–1.45; P < 0.0001). Availability of funds for systematic tracing was associated with better retention (aHR = 0.29; 95% CI: 0.16–0.55; P = 0.001).

Conclusions: Close follow-up, promoting early access to care and ART and a decentralized system of care may improve the retention in care of HIV-infected patients on ART.

Objectives: To estimate the proportion of all-cause adult patient attrition from antiretroviral therapy (ART) programs in service delivery settings in sub-Saharan Africa through 36 months on treatment.

Methods: We identified cohorts within Ovid Medline, ISI Web of Knowledge, Cochrane Database of Systematic Reviews and four conference abstract archives. We summarized retention rates from studies describing observational cohorts from sub-Saharan Africa reporting on adult HIV 1- infected patients initiating first-line three-drug ART. We estimated all-cause attrition rates for 6, 12, 18, 24, or 36 months after ART initiation including patients who died or were lost to follow-up (as defined by the author), but excluding transferred patients.

Results: We analysed 33 sources describing 39 cohorts and 226 307 patients. Patients were more likely to be female (median 65%) and had a median age at initiation of 37 (range 34-40). Median starting CD4 count was 109 cells/mm(3). Loss to follow-up was the most common cause of attrition (59%), followed by death (41%). Median attrition at 12, 24 and 36 months was 22.6% (range 7%-45%), 25% (range 11%-32%) and 29.5% (range 13%-36.1%) respectively. After pooling data in a random-effects meta-analysis, retention declined from 86.1% at 6 months to 80.2% at 12 months, 76.8% at 24 months and 72.3% at 36 months. Adjusting for variable follow-up time in a sensitivity analysis, 24 month retention was 70.0% (range: 66.7%-73.3%), while 36 month retention was 64.6% (range: 57.5%-72.1%).

Conclusions: Our findings document the difficulties in retaining patients in care for lifelong treatment, and the progress being made in raising overall retention rates.

The scale-up of antiretroviral therapy (ART) has been one of the success stories of sub-Saharan Africa, where coverage has increased from about 2% in 2003 to more than 40% 5 years later. However, tempering this success is a growing concern about patient retention (the proportion of patients who are alive and remaining on ART in the health system). Based on the personal experience of the authors, 10 key interventions are presented and discussed that might help to improve patient retention. These are (1) the need for simple and standardized monitoring systems to track what is happening, (2) reliable ascertainment of true outcomes of patients lost to follow-up, (3) implementation of measures to reduce early mortality in patients both before and during ART, (4) ensuring uninterrupted drug supplies, (5) consideration of simple, non-toxic ART regimens, (6) decentralization of ART care to health centres and the community, (7) a reduction in indirect costs for patients particularly in relation to transport to and from clinics, (8) strengthening links within and between health services and the community, (9) the use of ART clinics to deliver other beneficial patient or family-orientated packages of care such as insecticide-treated bed nets, and (10) innovative (thinking ‘out of the box’) interventions. High levels of retention on ART are vital for individual patients, for credibility of programmes and for on-going resource and financial support.

Objectives: To ascertain the outcome of pre-Antiretroviral therapy (ART) and ART patients defaulting from care and investigate reasons for defaulting.

Methods: Patients defaulting from HIV care in Chiradzulu between July 2004 and September 2007 were traced at last known home address. Deaths and moves were recorded, and patients found alive were interviewed. Defaulting was defined as missed last appointment by more than 1 month among patients of unknown vital status.

Results: A total of 1637 individuals were traced (54%–88% of eligible), 981 pre-ART and 656 ART patients. Of 694 pre-ART patients found, 49% had died (51% of adults and 38% of children), a median of 47 days after defaulting, and 14% had moved away. Of 451 ART patients found, 54% had died (54% of adults and 50% of children), a median of 52 days after defaulting, and 20% had moved away. Overall, 221 patients were interviewed (90% of those found alive), 42% had worked outside the district in the previous year; 49% of pre-ART and 19% of ART patients had not disclosed their HIV status to other household members. Main reasons for defaulting were stigma (43%), care dissatisfaction (34%), improved health (28%) and for ART discontinuation, poor understanding of disease or treatment (56%) and drug side effects (42%).

Conclusion: This study in a rural African HIV programme reveals the dynamics related to health service access and use, and it provides information to correct programme mortality estimates for adults and children.

Objectives: To better understand the reasons why patients default from antiretroviral treatment (ART) programmes to help design interventions that improve treatment retention and ultimately, patient outcomes.

Methods: Prospective cohort study at two treatment sites in South Africa followed by qualitative interviews with patients that had defaulted.

Results: Respondents overwhelmingly reported that ART improved their health status and quality of life. Nevertheless, despite improved health from taking ART and worse health when treatment is stopped, serious barriers to treatment remained: transport costs, time needed for treatment, and logistical challenges were barriers to treatment, whereas stigma around HIV/AIDS, and side effects associated with ART were less influential.

Conclusion: With a better understanding of the reasons for defaulting, interventions can be designed that improve treatment retention and ultimately, patient outcomes. This study argues for realistic interventions and policy changes designed to reduce the financial and time burden of ART and to reduce logistical barriers, such as simplifying the referral and transfer process, employing patient advocates, and adopting extended and weekend clinic hours.

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