In resource-limited settings, there has been a significant increase in access to antiretroviral therapy (ART) in recent years. In 2010, 6.6 millio people had access to ART in low- and middle-income countries, increasing by 16-fold compared to access in 2003. Although there remain serious limitations in access to ART in these settings, for many who have initiated and continue treatment, HIV disease is a chronic condition that needs to be managed over time. There is considerable evidence that individuals with chronic illness have an increased risk of depression, in part related to the challenges in coping and managing their illness. Among persons living with HIV and AIDS (PLHA) in Tanzania, the prevalence of symptoms comparable to major depressive disorder (moderate to severe depression) was reported as 10.5%, with over 45% presenting with milder forms of depression in an urban setting. Rates for depression during pregnancy in women living with HIV are estimated to be higher, with more than 40% experiencing symptoms comparable to major depressive disorder (MDD). Despite this relatively high burden of depression among PLHA, it has been documented that clinical staff working with PLHA do not routinely identify or treat depression in this setting. This is in contrast to recent revisions in the Tanzanian health policy that emphasize integrating mental health and HIV care at district and lower level health care services. The long-term intent of the research is to bridge this gap between Tanzanian health policy and implementation of integrating mental health care among pre- and post-natal women receiving HIV care. Therefore, the overall goal of the proposed study is to examine the potential for successful integration of enhanced mental health care and group counseling among HIV- positive women receiving PMTCT-plus services and to evaluate a combination of evidence-based approaches in treatment of depression in this vulnerable population in Tanzania. Specifically this application aims to: 1) Examine the acceptability and feasibility of integrating n enhanced standard of mental health care and group counseling with PMTCT-plus services provided at government-run maternal and child health (MCH) clinics, from the perspectives of: a) facility mental health care focal points and MCH clinic managers, b) perinatal direct care providers; and c) HIV-positive perinatal women; 2) Validate a depression screening tool for major depressive disorder (MDD) and suicidality for use in Tanzania; and 3) Conduct a cluster randomized controlled trial comparing a task-sharing approach (i.e. problem solving and cognitive behavioral therapy components delivered to groups facilitated by lay community based health care workers; CBHWs) versus improved standard of care for the treatment of depression among HIV-positive women accessing PMTCT-plus services.
Although there is a significant burden of depression among HIV-positive women in Tanzania, there is a critical gap between the needs of this population and the integration of mental health and PMTCT-plus services. The long-term intent of the research is to bridge this gap with the overall goal to examine the potential for successful integration of enhanced mental health care and brief group interventions among HIV-positive women receiving PMTCT-plus services and to evaluate a combination of evidence-based approaches for treatment of depression in this vulnerable population in Tanzania.