Mental health comorbidities are common in HIV-infected populations, and depression is frequently the most prevalent and highly neglected despite evidence of is adverse effects on adherence to antiretroviral treatment (ART), cognitive and immunological function, and risky behavior. The measurement, monitoring and support to reduce adverse outcomes and needless suffering from depression is woefully inadequate in most HIV clinical care worldwide, and frequently negligible in low-and-middle income countries (LMICs). In Haiti, it is largely nonexistent. After Sub-Saharan Africa, the most HIV-affected region in the world is the Caribbean;50% of people with HIV infection live in Haiti, one of the most challenging and deprived environments among LMICs. Managed approaches to depression, including algorithm-guided antidepressant treatment, have shown efficacy in general primary care populations and recent promise in the care of HIV patients in the United States. However, they have not been studied for use with auxiliary personnel in LMICs. Without integrated psychosocial care and support, gains against the epidemic from ART scale up in these countries will not be sustainable. LMICs like Haiti offer an opportunity to build on the ART clinical network to create similar measurement, monitoring and support models in mental health, which can be used as a source of innovation in the general health system. We propose a study to develop and evaluate an auxiliary-driven model of depression management among HIV positive individuals initiating ART at the Groupe Haitien d'Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO) centers in Port-au-Prince, which is responsible for 50% of the ART population in Haiti. Our proposed approach is based on an evidence-based model of measurement-based care (MBC), which guides HIV clinical staff and physicians in algorithm- based antidepressant treatment. We will conduct a pilot and evaluate feasibility and costs in a small randomized clinical trial (RCT). This proposed R21 developmental and exploratory study will produce the first systematic formative work of psychosocial factors related to depression in Haiti, and will be the first to apply and test the MBC approach with auxiliary personnel in an LMIC's ART system.
Depression is often the most prevalent mental health problem among people living with HIV (PLWH), and if not adequately treated, it may impair response to antiretroviral treatment (ART) and the ability of individuals to adhere to medications and healthy behavior. Most patients with depression receiving ART in the poorest countries of the world are left untreated because no systematic approach or expertise is available. We will adapt an evidence-based model of depression care using auxiliary HIV clinic staff, and test feasibility and assess costs among HIV positive patients beginning ART in urban Haiti.
