DEPRESSION SCREENING AND TREATMENT FOR PEOPLE INITIATING HIV CARE IN MALAWI

Depression is highly prevalent among people living with HIV in Malawi and elsewhere in sub-Saharan Africa (SSA). Beyond the morbidity produced by depression in its own right, depression is also an important barrier to early and consistent HIV care engagement and long-term viral suppression. Depression treatment has been linked to improved antiretroviral therapy (ART) adherence in observational studies, although evidence from interventions is mixed. To address the burden of depression among people living with HIV, the Malawi Ministry of Health implemented a pilot program that integrates depression screening and treatment into public HIV care at two clinics in Lilongwe, Malawi. Using abstracted clinical data from patients enrolled in the program evaluation as well as in-depth interviews with patients and health care facility staff, this dissertation aims to 1) estimate the association between baseline depression and retention in HIV care and viral suppression; 2) evaluate the impact of depression treatment on retention in HIV care, viral suppression, and depression remission; and 3) explain the success or failure of the program implementation using a mixed-methods approach that focuses on fidelity, acceptability and sustainability. Among the 1091 participants screened for depression prior to the launch of the treatment program included in Aim 1, the prevalence of depression was 27%. Those with depression had similar HIV care outcomes at 6 months to those without depression. Among the participants with elevated depressive symptoms at ART initiation included in Aim 2, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)]. The mixed-methods process evaluation presented in Aim 3 found that fidelity to the program protocol was poor and the program was not delivered as intended. While antidepressants and problem-solving therapy appeared to be acceptable treatment options for patients, clinic staff and leadership found delivering this treatment challenging in light of constrained human resources and infrastructure. The program was ultimately not sustained. As designed and without substantial support to supervise the implementation of the program, continue to build and maintain the capacity of providers, integrate the program into the electronic medical records system and ensure the availability of counselors, it does not appear feasible to integrate this depression treatment program into HIV care in this setting.Doctor of Philosoph