Mental health burden of HIV/AIDS in developing countries by David Ndetei

MENTAL HEALTH BURDEN OF HIV/AIDS IN DEVELOPING COUNTRIES BY DAVID M. NDETEI PROFESSOR OF PSYCHIATRY UNIVERSITY OF NAIROBI, KENYA & DIRECTOR, AFRICA MENTAL HEALTH FOUNDATION (AMHF) Website: www.africamentalhealthfoundation.org

1) The WHO Executive Board during their 124th session in a meeting on 20th November 2008 considered a report by the WHO Secretariat entitled “HIV/AIDS and Mental Health” I believe this report to be the most authoritative summary of all the evidence linking HIV/AIDS and mental health.

2) OUTLINE My talk will draw a lot from this report Illustrate the global scale and then have a quick look at Kenyan data Summarize the priorities for action, opportunities and challenges I hope I will be able to convince you that indeed we can live up to the challenge.

3) First on Global scale

4) Mental health and HIV/AIDS are closely interlinked; Mental health problems, including substance- use disorders, Associated with increased risk of HIV infection and AIDS and interfere with their treatment, Conversely some mental disorders occur as a direct result of HIV infection

5. Studies in both low- and high-income countries have reported higher rates of depression in HIV-positive people compared with HIV negative control groups

6) Some studies have reported behavioural risk factors for transmission of HIV in between 30% and 60% of people with severe mental illnesses. The prevalence of mental illnesses in HIV- infected individuals is substantially higher than in the general population: - High rates of sexual contact with multiple partners, Injecting drug use, Sexual contact with injecting drug users, Sexual abuse (in which women are particularly vulnerable to HIV infection),

Unprotected sex and low use of condoms.Mental disorders may interfere with the ability to acquireand/or use information about HIV/AIDS and thus to practicesafer behaviours or increase the likelihood of situationsoccurring in which risk behaviours are more common.Mental and substance-use disorders affect help-seekingbehaviour or uptake of diagnostic and treatment services forHIV/AIDS. Mental illnesses have been associated with lowerlikelihood of receiving antiretroviral medication.Substance-use disorders affect both the progression of HIVdisease and the response to treatment.

7) Therefore it is not surprising that there is a high seroprevalence of HIV infection in people with serious chronic mental illnesses

8) HIV/AIDS and injection drugs use: - About 10% of HIV cases worldwide are attributable to injecting drug use About three million injecting drug users might be infected with HIV.

9) The Burden: HIV/AIDS is a significant cause of death and disability, especially in low- and middle-income countries. UNAIDS estimates that in 2007, 33 million people were living with HIV. HIV/AIDS imposes a significant psychological burden. People with HIV often suffer from depression and anxiety as they adjust to the impact of the diagnosis, for instance shortened life expectancy, complicated therapeutic regimens, stigmatization, and loss of social support, family or friends. HIV infection can be associated with high risk of suicide or attempted suicide. The psychological predictors of suicidal ideation in HIV-infected individuals include concurrent substance-use disorders, past history of depression and presence of hopelessness.

Apart from psychological impact, HIV infection has directeffects on the central nervous system, and causesneuropsychiatric complications including HIVencephalopathy, depression, mania, cognitive disorder,and frank dementia, often in combination.Infants and children with HIV infection are more likely toexperience deficits in motor and cognitive developmentcompared with HIV negative children.Cognitive impairment in HIV/AIDS has been associatedwith greatly increased mortality, independent of otherfactors such as baseline clinical stage, CD4+ cell count,serum haemoglobin concentration, antiretroviral treatment,and social and demographic characteristics.

(a) URBAN AREAS Table 1: Methods/Routes Of Use Of Drugs (%) Mombasa Malindi Nairobi Nakuru Kisumu n=314 n=75 n=340 N=222 n=209Swallow 33.4 16.0 47.4 59.5 72.2Smoke 43.9 62.7 30.6 32.4 23.9Snort/Sniff 5.7 0.0 5.0 5.0 1.4Inject 12.1 21.3 15.9 0.9 1.9Others 4.8 0.0 1.2 2.3 0.5 Oral (45.7% on average) and nasal (38.7%) were by far the most common modes of consumption of drugs, followed by parenteral administration (injectable) at 10.4% on average (table 3).

TABLE 2(a) : PATTERN OF DRUG INJECTION (%) Mombasa Malindi Nairobi Nakuru Kisumui. Annual prevalence rates ofIDUsOnce a week 1.1 0.5 12.9 6.1 4.3More than once a week 1.7 9.3 34.9 3.3 11.2Once a day 2.9 0.5 4.4 2.0 0More than once a day 17.1 10.4 3.8 0.4 0Non-injectors 77.1 89.6 44.0 88.2 84.5ii. Injecting self alone. Yes 12.9 0.5 12.9 4.9 2.2iii. Annual use of needle afterothers. YesOnce 5.1 9.3 26.1 3.7 12.6Up to 5 times 3.7 0 3.8 1.2 0More than 5 times 4.3 0.5 7.1 3.7 0iv. Use of the needle afterothers. YesOne person 4.6 0 3.0 4.1 0.7Upto 5 people 3.7 0 3.0 0.4 0More than 5 people 3.7 0.5 6.6 2.4 0v. Dispensing used needle toothers in 12 months. YesOnce 3.7 2.7 17.0 2.0 32.5Up to 5 times 2.9 0.9 3.3 1.6 0More than 5 times 4.3 0.5 6.6 3.7 0

TABLE 2(b) : PATTERN OF DRUG INJECTION (%) Mombasa Malindi Nairobi Nakuru Kisumuvi. Cleaning needles before re-use in 12 months. YesEvery time 8.9 1.6 3.8 2.0 1.1Sometimes 9.1 0 8.8 1.6 2.9Never 4.3 0 11.3 14.6 1.1vii. Bleaching needle in thelast 12 months. YesEvery time 1.7 1.6 10.2 3.7 24.2Sometimes 2.3 5.5 23.6 2.4 15.2Never 20.3 2.7 30.8 19.9 24.9viii. Equipment cleaning inways other than aforementioned. explain:Boiling 4.9 0.5 3.6 4.9 0.4Disinfectant 0.9 0 1.9 3.3 0Direct heating 0 0 0.5 0.4 0Other 10.6 0 0.5 0.8 0

TABLE 3a: NEEDLE SHARING BEHAVIOR Use of a needle after someone Study Sites else in the last 12 months (%) Never Once Up to >5 5 times times Mombasa 47.1 35.3 17.5 0.0 Malindi 0.0 0.0 0.0 100.0 Nairobi 37.1 17.1 14.3 31.4 Nakuru 73.3 13.3 6.7 6.7 Kisumu 80.0 0.0 0.0 0.0 Average 47.5 13.1 7.7 27.6Those who knew that they were HIV positive used needles thathad just been used by somebody else. This practice was mostfrequent in Malindi and Nairobi but was not found in Kisumu.

TABLE 3b: DRUG INJECTION & HIV STATUS Others using needle before HIV status +ve. respondent in the last 12 months (%) No One Up to 5 >5 person person people people Mombasa 46.7 26.7 26.7 0.0 Malindi 0.0 0.0 0.0 100.0 Nairobi 44.0 12.0 8.0 36.0 Nakuru 73.3 26.7 0.0 0.0 Kisumu 100.0 0.0 0.0 0.0 Average 52.8 13.1 6.9 27.2Those who knew that they were HIV positive passed on the needles they had usedto others to also use. This practice was commonest in Malindi, followed by Nairobibut was not found in Kisumu. Thus awareness in HIV transmission and positive inHIV status was not reflected in the practice of sharing needles, at least on the partof those who already knew their positive status. However the findings for Malindishould be seen in the light of Table 3d below.

TABLE 3c: DRUG INJECTION & HIV STATUS Other people using a needle after the respondentHIV status in the last 12 months (%)+ve. Never Once Up to 5 >5 times timesMombasa 66.7 6.7 26.7 0.0Malindi 0.0 0.0 0.0 100.0Nairobi 40.0 20.0 14.3 25.7Nakuru 66.7 20.0 13.3 0.0Kisumu 80.0 0.0 0.0 0.0Average 50.7 9.3 10.9 2.5 This table reflects the findings of Table 3b.

TABLE 3d: DRUG INJECTION & HIV STATUS Cleaning of needles before re-use in the last HIV status +ve. 12 months (%) No Every Someti Never re-use time mes Mombasa 21.4 7.1 28.6 42.9 Malindi 0.0 100.0 0.0 0.0 Nairobi 18.5 18.5 29.6 33.3 Nakuru 13.3 13.3 0.0 73.3 Kisumu 100.0 0.0 0.0 0.0 Average 30.6 27.8 11.6 30.0Malindi cohort always cleaned their needles, thus putting intopractice their knowledge on the risks involved in sharing needles.In Kisumu there was no sharing of needles. In all the other cohorts,majority cleaned only sometimes or never.

TABLE 3e: DRUG INJECTION & HIV STATUS Bleaching needles before use in HIV status +ve. the last 12 months (%) Every Someti Never time mes Mombasa 0.0 0.0 100.0 Malindi 0.0 0.0 100.0 Nairobi 16.2 35.1 48.6 Nakuru 0.0 13.3 86.7 Kisumu 20.0 0.0 80.0 Average 7.2 9.7 83.1Bleaching of needles was a practice found only in upcountrycohorts.

TABLE 3f: DRUG INJECTION & HIV STATUS Sharing of equipment HIV status +ve. other than needles (%). Yes No Mombasa 10.7 14.3 Malindi 50.0 0.0 Nairobi 16.1 33.3 Nakuru 0.0 2.8 Kisumu 0.0 100.0 Average 35.4 29.5 Drug injectors who knew they were HIV positive shared equipments related to drug use other than needles in all the cohorts except in Nakuru and Kisumu.

TABLE 3g: DRUG INJECTION & HIV STATUS Sexual intercourse without a condom under HIV status +ve. influence of drugs. (%) Not at all Sometimes Always Mombasa 44.0 16.0 40.0 Malindi 0 0 0 Nairobi 56.0 36.0 8.0 Nakuru 22.2 38.9 38.9 Kisumu 50.0 33.3 16.7 Average 43.1 31.1 25.9In spite of knowing that they were HIV positive the cohortspracticed unprotected sex in the majority of the cases. There istherefore no relation between knowing they are HIV positive andthe practice of safe sex.

TABLE 4: USE OF CONDOMS VS HIV STATUS (%) Mombasa Malindi Nairobi Nakuru KisumuFrequency of use acondom whenever youhave sex Vs. awareness ofHIV statusNot at all 20.0 35.0 22.4 27.1 32.3Sometimes 42.1 35.0 55.2 43.9 41.2Always 37.9 28.8 22.4 29.0 26.5Frequency of use ofcondom whenever youhave sex Vs. HIV statusNot at all 19.0 37.5 27.7 30.8 34.5Sometimes 53.2 29.2 47.7 48.7 34.6Always 27.8 33.2 24.6 20.5 26.9 Whether they were aware of HIV status or not, the majority did not use condom during sex, again reflecting a gap between knowledge on HIV transmission and practice.

LABORATORY RESULTS Note: No. = Number A total of 120 were recruited, 111 males and 9 females No. of drug abusers tested 120 Percentage HEPATITIS C + 73 60.83 HIV + 50 41.66 No. of IDU’s tested 101 Percentage HEPATITIS C + 71 70.29 HIV + 50 49.50Of the total sample of 120, seventy three tested positive forHepatitis C (60.83%) and 50 tested positive for HIV(41.66%). Out of that sample 101 were I.D.U’s. All whotested positive for HIV (50) were IDU’s (49.5%), and70.29% who tested positive for Hepatitis C were I.D.U’s.

AGE DISTRIBUTION(A)Age No. of drug abusers tested 120 Percentage 17 – 30 65 54.2 31 – 40 43 35.8 41 – 52 12 10

(B)Age No. of drug HCV abusers tested HIV + Percentage + Percentage17 - 30 65 27 22.5 39 32.531 - 40 43 19 15.83 29 24.1641 - 52 12 4 3.33 5 4.16TOTAL 120 50 44.66 73 60.82

(C) No. of drug HIV HCV Age abusers tested + Percentage + Percentage17 - 30 65 27 26.73 39 38.6131 - 40 43 19 18.81 27 26.7341 - 52 12 4 3.96 5 4.95TOTAL 101 50 49.5 71 79.29

(D) No. of drug abusers HIV HCVAge tested 120 + Percentage + Percentage17 - 30 65 27 41.53 39 6031 - 40 43 19 44.1 29 67.4441 - 52 12 4 33.33 5 41.66

(E) No. of drugAge abusers tested 120 HIV + Percentage HCV + Percentage17 - 30 65 27 41.53 39 6031 - 40 43 19 44.1 27 62.7941 - 52 12 4 33.33 5 41.66

GENDER(A)Gender No. of drug abusers Percentage tested 120MALE 111 92.5FEMALE 9 7.5 (B)Gender No. of IDU tested 101 PercentageMALE 94 93.06FEMALE 7 6.94The low turnout of females to participate in the study can beattributed to the following:- 1. Their low number in general. 2. Their fear of being tested, as many of them are also commercial sex workers. 3. Little attention has been paid to them as an affected group up to now.

(C)GENDER # OF IDU # HIV + # HEPATITIS C + TESTEDMALE 94 46 66FEMALE 7 6 5Out of the 7 female IDU’s, six tested positive forHIV/Aids and 5 tested positive for Hepatitis C. Out ofthe 94 male IDU’s, 46 tested positive for HIV/Aids and66 tested positive for Hepatitis C.Of the total sample of 120, seventy three testedpositive for Hepatitis C (60.83%) and 50 testedpositive for HIV (41.66%). Out of that sample 101were IDUs. All those who tested positive for HIV (50)were IDUs (49.5%).

(B) IN A RURAL SETTINGTable 1a: - HIV/AIDS STATISTICS FOR THE STUDY SITES Reporting Period KIBWEZI (EXPERIMENTAL SITE) MTITO ANDEI (CONTROL SITE) Grand Grand ST Children Adults Totals Totals Children Adults Totals Totals JAN 2010 - DEC 31 2010 0-14yrs >14yrs 0-14yrs >14yrs F M F M F M F M F M F M Number of new PMCT clients 0 0 20 0 20 20 1 0 26 0 21 21 patients enrolled VCT clients 6 2 10 6 16 8 24 8 3 46 16 54 19 73 within the month TB patients 0 1 6 8 6 9 15 0 0 3 3 3 3 6 1 for HIV care by In patients 0 0 1 0 1 0 1 0 0 15 5 15 5 20 entry point within CWC 5 1 0 0 5 1 6 1 1 0 0 1 1 2 the reporting All others 13 27 237 98 250 125 375 24 7 134 48 124 55 179 period Sub-total 24 31 274 112 298 143 441 34 11 224 72 218 83 301 Cumulative Number of persons 2 enrolled in HIV care at this facility within the reporting period 70 102 770 362 840 464 1304* 76 69 617 195 693 264 957* Number of patients WHO stage 1 1 1 5 0 6 1 7 5 5 18 5 23 10 33 starting ARVs by WHO stage 2 5 5 31 1 36 6 42 5 4 32 5 37 9 46 3 WHO stage within WHO stage 3 2 4 27 4 29 8 37 3 3 44 10 47 13 60 the reporting WHO stage 4 0 0 1 0 1 0 1 3 1 5 0 8 1 9 period Sub-total 8 10 64 5 72 15 87 16 13 99 20 115 33 148 Cumulative Number of persons 4 started on ARVs at this facility during the reporting period 41 41 325 187 366 228 594* 42 46 391 94 433 140 573* Pregnant Total Number of women 0 2 2 2 0 10 10 10 5 patients currently All others 41 41 325 187 366 228 594 40 38 320 87 360 125 485 on ARVs Sub-total 41 41 327 187 368 228 596* 40 38 330 87 370 125 495* Number of persons who are enrolled and eligible for ART but have not 6 been started on ART during the reporting period 0 0 0 0 0 0 0 21 10 113 43 134 53 187 Post exposure Sexual assault 2 0 6 3 8 3 11 4 0 4 1 8 1 9 prophylaxis(PEP) Occupational 0 0 0 0 0 0 0 0 0 0 0 0 0 0 7 Within the All others 0 0 0 0 0 0 0 1 0 3 7 4 7 11 reporting period Sub-total 2 0 6 3 8 3 11 5 0 7 8 12 8 20 Total Number of Cotrimoxazole 70 102 770 362 840 464 1304 68 65 556 172 624 237 861 patients currently Fluconazole 0 0 0 0 0 0 0 0 2 15 10 15 12 27 8 on prophylaxis during the reporting period Sub-total 70 102 770 362 840 464 1304* 68 67 571 182 639 249 888*

Table 1b: - HIV/AIDS STATISTICS FOR THE STUDY SITES Reporting Period KIBWEZI (EXPERIMENTAL SITE) MTITO ANDEI (CONTROL SITE) Children Adults >14yrs Totals Children Adults >14yrs Totals ST 0-14yrs Grand 0-14yrs Grand JAN 2011 - MAY 31 2011 Totals Totals F M F M F M F M F M F M 1 Number of f new PMCT clients 0 7 7 7 0 4 4 4 patients enrolled VCT clients 2 0 6 1 8 1 9 3 1 8 6 11 7 18 within the month TB patients 0 0 3 3 3 3 6 0 0 0 1 0 1 1 for HIV care by In patients 0 0 0 0 0 0 0 3 0 23 7 26 7 33 entry point within CWC 0 0 0 0 0 0 0 0 0 0 the reporting All others 5 7 47 13 52 20 72 5 5 37 10 42 15 57 period Sub-total 7 7 63 17 70 24 94 11 1 12 5 18 6 24 2 Cumulative Number of persons enrolled in HIV care at this facility within the reporting period 77 109 833 379 910 488 1,398* 87 75 689 219 776 294 1,070* 3 Number of patients WHO stage 1 0 0 1 0 1 0 1 0 0 6 1 6 1 7 starting ARVs by WHO stage 2 2 5 5 3 7 8 15 0 2 20 4 20 6 26 WHO stage within WHO stage 3 0 0 10 8 10 8 18 3 1 23 6 26 7 33 the reporting WHO stage 4 0 1 0 0 0 1 1 0 0 6 1 6 1 7 period Sub-total 2 6 16 11 18 17 35 3 3 55 12 58 15 73 4 Cumulative Number of persons started on ARVs at this facility within the reporting period 43 47 341 198 384 245 629* 45 49 446 106 491 155 646* 5 Total Number of Pregnant patients currently women 0 2 2 2 0 16 16 16 on ARVs within All others 43 47 338 198 381 245 626 43 41 375 99 418 140 558 the reporting period Sub-total 43 47 340 198 383 245 628* 43 41 391 99 434 140 574* 6 Number of persons who are enrolled and eligible for ART but have not been started on ART within the reporting period 0 0 0 4 0 4 4 7 0 40 14 47 14 61 7 Post exposure Sexual assault 0 0 0 1 0 1 1 3 0 9 2 12 2 14 prophylaxis(PEP) Occupational 0 0 0 0 0 0 0 0 0 0 0 0 0 0 within the All others 0 0 0 0 0 0 0 0 0 0 0 0 0 0 reporting period Sub-total 0 0 0 1 0 1 1 3 0 9 2 12 2 14 8 Total Number of Cotrimoxazole 77 109 827 379 904 488 1392 79 70 628 197 707 267 974 patients currently Fluconazole 0 0 0 0 0 0 0 12 13 25 11 37 24 61 on prophylaxis within the reporting period Sub-total 77 109 827 379 904 488 1,392* 91 83 653 208 744 291 1,035* *Cumulative grand totals for the reporting period

CONCLUSIONS BASED ON KENYAN EXPERIENCE1) IDUs is an emerging phenomenon in Kenya, and there is urgent need for intervention practice to keep it in check2) There is a high correlation between IDUs and HIV in Kenya: - Laboratory tests on a cohort of IDUs in Mombasa found that 49.5% were HIV positive. This was a specially highly motivated cohort requested to come forward for testing and may therefore have been a cause of underestimation of the percentage of linkages. An average of 68-88% of different cohorts of IDUs very active in drug abuse and injecting drug abuse were HIV positive.

3) There is an urgent need to prevent IDU from becoming a major vector of HIV in Kenya4) This study indicates homosexuality as an emerging sexual practice in Kenya. This was particularly found amongst youth, drug users and IDUs5) In spite of knowledge on how HIV is transmitted, this is not reflected in both drug abuse and sexual activity pattern6) The research indicates that drug abuse predisposes to risky sexual behaviour. This in turn fuels more drug abuse. This was confirmed by qualitative data

Recommendations1) There is an urgent need to develop new policy on IDU and its relationship to HIV.2) There is an urgent need to translate policy into action in a comprehensive inclusive way.3) Urgent research is required to bridge the gap between knowledge and practice in relation to drug abuse, injecting drug use, sexual practice and HIV.4) Timely interventions are indicated to limit the spread of HIV among drug users and Injecting Drug Users.

GENERAL PRIORITIES FOR ACTION1) Integration of mental health and HIV/AIDS diagnostic, information and mental health systems: - Integrated training tools for diagnosis Joint management Supervision

2) Appropriate policy to back the integration3) Operational research so that developing countries can have their own data It is unacceptable that despite the fact that developing countries carry more than 90% of the burden of HIV/AIDS, little information about the interaction between HIV/AIDS and mental health is available from low and middle-income countries.

YES WE CAN!!!

Mental health burden of HIV/AIDS in developing countries by David Ndetei

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Mental health burden of HIV/AIDS in developing countries by David Ndetei Presentation Transcript