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People with severe mental health conditions deserve better HIV programming

People with severe mental health conditions are being neglected when it comes to HIV prevention and treatment programmes. This is despite the concern that people with severe mental health conditions such as Bipolar 1 are more likely to put themselves at risk of HIV because of risky sexual behaviour, and children with severe mental health conditions (SMHC) are more likely to be victims of sexual abuse and thus at a higher risk of contracting HIV.

October 10 is Global Mental Health Awareness Day, and this year, the theme is “Mental health is a universal human right”. Masiviwe, let’s be heard, a South African mental health project, is focusing its attention for the month on advocating that people with severe mental health conditions be included as a key population in HIV programmes.

Currently, key populations that have been identified for additional attention when it comes to HIV programming are: men who have sex with men, sex workers and their clients, transgender people, people in prisons or other closed institutions and people who inject drugs. UNAIDS defines key populations as “groups of people who are more likely to be exposed to HIV or to transmit it and whose engagement is critical to a successful HIV response”. In an opinion piece shortly to be published in the AIDS journal, a group of authors led by Professor Melvyn Freeman, together with Dr Gustaaf Wolvaardt, CEO of the Foundation for Professional Development (FPD), and Professor Milton Wainberg of Columbia University, NY, estimate that 23% of people with severe mental health conditions are living with HIV. This is higher than two of the already identified key populations (prison population and people who inject drugs), and in actual numbers, higher than these two groups, as well as sex workers, another key population group. The authors argue that people with SMHC meet all the criteria for inclusion as a KP in terms of risk, vulnerability and prevalence.

Designation as a key population has major implications, especially for prevention programming budget allocation. Both international and locally funded HIV programmes have dedicated initiatives for key populations. “The type of HIV prevention and treatment services that people with severe mental health conditions are missing out on include targeted preexposure prophylaxis (PrEP), postexposure prophylaxis (PEP), as well as routine HIV testing and education programmes”, says Freeman. “There are also no internationally agreed-upon guidelines to support the prevention, screening and management of people who have both HIV and SMHC”.

The recently adopted South African National Strategic Plan (NSP) for HIV, TB and STIs 2023-2028 identified that integrating mental health into HIV and TB care is vital. “The new NSP is already a big step forward in integrating mental health care into HIV/TB/STI treatment with a substantial increase in emphasis on identifying common mental health conditions such as depression and anxiety,” says CEO of FPD, Dr Gustaaf Wolvaardt.

The leader of a South African Anxiety and Depression Group (SADAG) HIV support group, Louise Kotsokoane, who lives with HIV and Bipolar, cautioned that the focus on people with severe mental health conditions as a key population for HIV programming should not be misread as implying that people who are diagnosed with HIV have severe mental health problems. “There are two sides to this coin. People who are diagnosed with HIV also tend to develop mental health conditions, such as depression, anxiety, stress, anger. I believe that the mental health issues related to an HIV diagnosis during the process of an individual getting to acceptance of their diagnosis are also important. People also have to deal with stigma and disclosure issues”.

Masiviwe, which kicked off last year, is aimed at building a broad society movement to leverage all sectors of society working on improving access to mental health care. This project is a spinoff from FPD’s Improving Mental Health and HIV/TB Service Integration in South Africa under the President’s Emergency Plan for AIDS Relief (PEPFAR) (IMHSI) project funded through CDC, the first major donor investment into integrating mental health care into South Africa’s HIV/TB system strengthening efforts.

“Masiviwe as a whole focuses on a number of key issues around mental health, including mental health literacy, fighting stigma, calling for increased access to mental health care, as well as integrating mental health and HIV/TB services,” says Communications co-ordinator for Masiviwe, Jennifer Charlton. “We’ve chosen this specific issue as a focus for our Mental Health Awareness month campaign this year, as we feel it’s an important issue for both mental health and for reaching HIV prevention and treatment targets”.

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