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HIV remains a pressing global health problem, with 1.5 million new infections reported globally in 2020. HIV pre-exposure prophylaxis (PrEP) can lower the likelihood of HIV acquisition among populations at elevated risk, yet its global roll-out has been discouragingly slow. Psychosocial factors, such as co-occurring mental illness and substance use, are highly prevalent among populations likely to benefit from PrEP, and have been shown to undermine persistence and adherence. In this analysis, we review the high burden of mental health problems among PrEP candidates and contend that inattention to mental health stands to undermine efforts to implement PrEP on a global scale. We conclude that integration of mental health screening and treatment within PrEP scale-up efforts represents an important strategy for maximising PrEP effectiveness while addressing the high burden of mental illness among at-risk populations. As implementers seek to integrate mental health services within PrEP services, efforts to keep access to PrEP as low-threshold as possible should be maintained. Moreover, programmes should seek to implement mental health interventions that are sensitive to local resource constraints and seek to reduce intersecting stigmas associated with HIV and mental illness.

Worldwide, people with mental disorders are detained within the justice system at higher rates than the general population and often suffer human rights abuses. This review sought to understand the state of knowledge on the mental health of people detained in the justice system in Africa, including epidemiology, conditions of detention, and interventions. We included all primary research studies examining mental disorders or mental health policy related to detention within the justice system in Africa. 80 met inclusion criteria. 67% were prevalence studies and meta-analysis of these studies revealed pooled prevalence as follows: substance use 38% (95% CI 26–50%), mood disorders 22% (95% CI 16–28%), and psychotic disorders 33% (95% CI 28–37%). There were only three studies of interventions. Studies examined prisons (46%), forensic hospital settings (37%), youth institutions (13%), or the health system (4%). In 36% of studies, the majority of participants had not been convicted of a crime. Given the high heterogeneity in subpopulations identified in this review, future research should examine context and population-specific interventions for people with mental disorders. Electronic supplementary material The online version of this article (10.1186/s13033-019-0273-z) contains supplementary material, which is available to authorized users.

OBJECTIVE: To document the lived experiences of people with both poor mental health and suboptimal adherence to antiretroviral therapy in high HIV prevalence settings.METHODS: In-depth qualitative interviews were conducted with 47 (female = 31) HIV-positive adults who scored above the cut-point on a locally validated scale for common mental disorders (CMDs). Purposive sampling was used to recruit participants with evidence of poor adherence. Six additional key informant interviews (female = 6) were conducted with healthcare workers. Data were collected and analysed inductively by an interdisciplinary coding team.RESULTS: The major challenges faced by participants were stressors (poverty, stigma, marital problems) and symptoms of CMDs ('thinking too much', changes to appetite and sleep, 'burdened heart' and low energy levels). Thinking too much, which appears closely related to rumination, was the symptom with the greatest negative impact on adherence to antiretroviral therapy among HIV-positive adults with CMDs. In turn, thinking too much was commonly triggered by the stressors faced by people living with HIV/AIDS, especially poverty. Finally, participants desired private counselling, access to income-generating activities and family engagement in mental health care.CONCLUSIONS: Better understanding of the local expression of mental disorders and of underlying stressors can inform the development of culturally sensitive interventions to reduce CMDs and poor adherence to antiretroviral therapy.

Summary There has been little external analysis of Zimbabwe's mental health system. We did a systems analysis to identify bottlenecks and opportunities for mental health service improvement in Zimbabwe and to generate cost-effective, policy-relevant solutions. We combined in-depth interviews with a range of key stakeholders in health and mental health, analysis of mental health laws and policies, and publicly available data about mental health. Five themes are key to mental health service delivery in Zimbabwe: policy and law; financing and resources; criminal justice; workforce, training, and research; and beliefs about mental illness. We identified human resources, rehabilitation facilities, psychotropic medication, and community mental health as funding priorities. Moreover, we found that researchers should prioritise measuring the economic impact of mental health and exploring substance use, forensic care, and mental health integration. Our study highlights forensic services as a central component of the mental health system, which has been a neglected concept. We also describe a tailored process for mental health systems that is transferable to other low-income settings and that garners political will, builds capacity, and raises the profile of mental health.

Introduction Few people with mental disorders in low and middle-income countries (LMICs) receive treatment, in part because mental disorders are highly stigmatized and do not enjoy priority and resources commensurate with their burden on society. Advocacy has been proposed as a means of building political will and community support for mental health and reducing stigma, but few studies have explored the practice and promise of advocacy in LMICs. Methods We conducted 30 semi-structured interviews with leaders in health and mental health in Zimbabwe to explore key stakeholder perceptions on the challenges and opportunities of the country’s mental health system. We coded the transcripts using the constant comparative method, informed by principles of grounded theory. Few interview questions directly concerned advocacy, yet in our analysis, advocacy emerged as a prominent, cross-cutting theme across participants and interview questions. Results Two thirds of the respondents discussed advocacy, often in depth, returning to the concept throughout the interview and emphasizing their belief in advocacy’s importance. Participants described six distinct components of advocacy: the advocates, to whom they advocate (“targets”), what they advocate for (“asks”), how advocates reach their targets (“access”), how they make their asks (“arguments”), and the results of their advocacy (“outcomes”). Discussion Despite their perception that mental health is widely misunderstood and under-appreciated in Zimbabwe, respondents expressed optimism that strategically speaking out can reduce stigma and increase access to care. Key issues included navigating hierarchies, empowering service users to advocate, and integrating mental health with other health initiatives. Understanding stakeholder perceptions sets the stage for targeted development of mental health advocacy in Zimbabwe and other LMICs.

Introduction & objectivesDue to the scale up of antiretroviral therapy, increasing numbers of HIV-infected children are living into adolescence. As these children grow and surpass the immediate threat of death, the issue of informing them of their HIV status arises. This study aimed to understand how perinatally-infected adolescents learn about their HIV-status as well as to examine their preferences for the disclosure process.MethodsIn-depth interviews were conducted with 31 (14 male, 17 female) perinatally-infected adolescents aged 16-20 at an HIV clinic in Harare, Zimbabwe, and focused on adolescents' experiences of disclosure. In addition, 15 (1 male, 14 female) healthcare workers participated in two focus groups that were centred on healthcare workers' practices surrounding disclosure in the clinic. Purposive sampling was used to recruit participants. A coding frame was developed and major themes were extracted using grounded theory methods.ResultsHealthcare workers encouraged caregivers to initiate disclosure in the home environment. However, many adolescents preferred disclosure to take place in the presence of healthcare workers at the clinic because it gave them access to accurate information as well as an environment that made test results seem more credible. Adolescents learned more specific information about living with an HIV-positive status and the meaning of that status from shared experiences among peers at the clinic.ConclusionsHIV-status disclosure to adolescents is distinct from disclosure to younger children and requires tailored, age-appropriate guidelines. Disclosure to this age group in a healthcare setting may help overcome some of the barriers associated with caregivers disclosing in the home environment and make the HIV status seem more credible to an adolescent. The study also highlights the value of peer support among adolescents, which could help reduce the burden of psychosocial care on caregivers and healthcare workers.

In The Lancet Psychiatry, Khameer Kidia and colleagues propose that carefully selected and trained adolescents living with HIV can effectively help the delivery of mental health care for other adolescents living with HIV. We concur, and want to bring attention to a National Institute of Child Health and Human Developmentfunded project in Kigali, Rwanda, where we are doing exactly what Kidia and colleagues recommend: trained HIV-positive Rwandan youths deliver a trauma-informed cognitive behavioural intervention to improve adherence to antiretroviral therapy in young people with HIV. Since 2004, Women’s Equity in Access to Care and Treatment (WEACTx) has provided integrated primary care to women, men, and children with HIV. Psychosocial services and support groups are an essential component of culturally sensitive quality care. HIV-positive youths attend support groups to develop social support and gain knowledge about HIV. Since 2010, adolescents aged 19 years and older have been trained as so-called peer parents to help counsellors in leading activities and discussions with younger youths. After observing successful engagement of peer parents and youths, we developed a youth-led group-based intervention to improve medication adherence in 14–21-year-olds at WE-ACTx and University Teaching Hospital of Kigali (CHUK) youth programmes. In January, 2013, we initiated a randomised controlled trial to assess a six-session youth-led intervention to increase antiretroviral therapy adherence compared with usual care. Working closely with Rwandan mental health providers and adolescents living with HIV, a US-based psychologist adapted an evidence-based intervention for the Rwandan context. The intervention addresses knowledge about HIV; safer sex practices; stigma; gender-based violence; trauma; cognitive behavioural strategies that promote learning connections between thoughts, feelings, and behaviours; and problemsolving skills to resolve adherence obstacles. Movement-based relaxation techniques are also practiced. 18 youth leaders from peer parent groups were selected from the WEACTx and CHUK youth programmes. Rwandan-trained psychologists with BA qualifications were recruited to supervise the youth leaders. The USA-based psychologist provided 14 days of training for the youth leaders, assisted by the psychologists, to teach the curriculum, practice the intervention strategies, review group dynamics and leadership skills, and receive feedback to improve their facilitation. Ongoing supervision is provided by a cascade approach, in which the US psychologist has weekly Skype calls with the psychologists who then supervise the youth leaders twice per week. In-person consultations with youth leaders and psychologists take place biannually. At study midpoint (April 4, 2015), 198 youths have completed baseline assessments, of whom 99 remain in usual treatment and 99 in intervention groups. After the 6-month and 12-month assessments, participants will attend a youth-led booster session and will be re-assessed at 18 months. Fidelity data collected by self-reports and observer reports for ten groups showed good observance to and delivery of the curriculum. Therefore, our experience supports the idea that adolescents living with HIV can eff ectively and with fi delity lead mental health interventions for HIV-infected youths. We are encouraged by the enthusiasm, competence, and confidence of the youth leaders during their training and their skill as intervention facilitators. We believe that adolescents living with HIV will have an important role in improving HIV care for themselves and other aff ected youths.