‘Urgent need’ to support the mental health of adolescents with HIV

Around one in four adolescents with HIV are likely to have a mental health condition. The Lancet has just released an evidence overview showing the scale of the issue, and what can be done about it.

What is this study about?

The mental health of adolescents with HIV, the current services available to them, and the type of support that works. Evidence reviews, trials and studies were all analysed.

Why is this research important?

Adolescents are less likely to access and stay on antiretroviral treatment (ART) than other age groups. They are also more likely to take risks with their sexual health.

Mental health is a factor in both things, so the right kind of mental health support could make a big difference. But HIV care tends to focus on biomedical treatment.

What did they find out?

Mental health issues are common: around 25% of adolescents with HIV have a mental health condition, such as depression, anxiety, post-traumatic stress or suicidal thoughts. Between 30–50% experience emotional distress.

Mental health is made worse by stigma, bullying, poverty, interruption of schooling, ART stockouts, family issues, orphanhood and living in a conflict-zone.

Effective approaches

Only a small proportion of adolescents with HIV get any mental health support. There is a lack of funding and trained staff. But evidence of the kind of mental health interventions that are effective is emerging.

Effective approaches to support individual adolescents to have good mental health include:

• problem-solving support
• cognitive behavioural therapy (CBT)
• bereavement support and memory work
• mindfulness.

Broader support that has a positive effect on adolescents’ mental health include:

• cash transfers that do not have specific conditions
• caregiver support and parenting programmes
• respectful and non-stigmatising healthcare
• care for pain and end of life for adolescents with AIDS.

It is effective to provide a mix of individual and broader interventions. In particular, community-based mental health support adapted for adolescents with HIV, family-based support and cash-based economic support.

The most effective way to deliver these interventions is through:

• trained peer supporters and mentor mothers
• trained community health workers
• trained clinic lay health workers
• support groups
• community-based organisations
• mental health professionals (where available)
• digital and online initiatives (limited evidence).

What does this mean for HIV services?

There is an urgent need to address the mental health of adolescents with HIV, and there is now good evidence about how to do this.

If you are working to support adolescents with HIV, it will be useful to adopt some of these approaches, and to advocate with policymakers and other decision-makers to adopt them.

Healthcare staff should understand adolescent mental health, including how specific mental health conditions and the emotional strain of the HIV care journey affect this age group. This can be done through sensitisation, capacity sharing, training and supervision.

Providing mental health support for adolescents with HIV should not be the sole responsibility of healthcare professionals. It should be shared with trained and supervised peer supporters, mentor mothers and lay health workers through community-based services. Adolescents with HIV can be trained to effectively provide problem-solving and CBT for their peers, for example.

Regularly screening adolescents with HIV for mental health conditions is essential. Some adolescents with HIV will have more severe conditions, such as major depression, psychosis or suicidal behaviour. Adolescents that are marginalised are particularly at risk of these. But all adolescents with HIV should be screened for the full range of conditions.

Where resources are available, referring adolescents with severe mental health conditions to qualified mental health professionals is essential. See the Mental Health Gap Action Programme and the Programme for Improving Mental Health Care for examples of good practice.

It is also important to have a simple, immediate mental health referral system between clinics, social work services and community-based programmes. Friendship Bench is a good example.

Preventing mental ill-health is also important. This can involve identifying moments when distress can occur, such as when an adolescent finds out they have HIV or if they lose a parent, and being ready with support.

Ensuring integrated HIV/mental health services are available in community settings or remotely can avoid the issue of stigma. This might encourage adolescents to use these services.

Whatever mental health support is introduced, it will be more effective if it is co-designed, delivered and evaluated by adolescents with HIV and their caregivers.