Leveraging Systems Science to Promote the Implementation and Sustainability of Mental Health and Psychosocial Interventions in Low- and Middle-Income Countries

ABSTRACT

Advancements in global mental health implementation research have revealed promising strategies for improving access to evidence-based mental health care. These advancements have not translated, however, into a reduced prevalence of mental disorders. In this review we examine the relationships between determinants (i.e., barriers and facilitators) and outcomes of mental health services in low- and middle-income countries to identify opportunities for improving the population-level impact and sustainability of innovations in global mental health. We identified three key implementation and services outcomes that influenced the prevalence of mental disorders in the 56 included review articles: supply (access, implementation), demand (help seeking, utilization), and quality (effectiveness, quality of care) of mental health services. Determinants of these outcomes revealed seven themes: community stakeholder engagement; cultural relevance; stigma; human resource capacity; organization of services; governance, policy, and financing; and sociopolitical and community context. We developed a causal loop diagram to illustrate the relationships among these determinants and outcomes. The causal loop diagram revealed the central role of community stakeholder engagement in bridging implementation and patient outcomes, the importance of addressing stigma and social determinants of mental health, and the need to complement supply-side implementation strategies with approaches to equilibrate demand and improve the quality of services. Applying systems science methodologies to global mental health research presents an opportunity to examine the complex relationships among community and health system factors that influence implementation of evidence-based interventions in order to identify sustainable approaches to improve the population-level impact of mental health services in low- and middle-income countries.

Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence-Based Practices (PRIDE) in Mozambique

BACKGROUND

Mental health conditions impose a major burden worldwide, especially in low- and middle-income countries (LMICs), where health specialists are scarce. A challenge to closing LMICs' mental health treatment gap is determining the most cost-effective task-shifting pathway for delivering mental health services using evidence-based interventions (EBIs). This article discusses the protocol for the first study implementing comprehensive mental health services in LMICs.

METHODS

In partnership with the Mozambican Ministry of Health, this cluster-randomized, hybrid implementation effectiveness type-2 trial will evaluate implementation, patient, and service outcomes of three task-shifting delivery pathways in 20 Mozambican districts (population 4.7 million). In pathway 1 (usual care), community health workers (CHWs) and primary care providers (PCPs) refer patients to district-level mental health clinics. In pathway 2 (screen, refer, and treat), CHWs screen and refer patients to PCPs for behavioral and pharmacological EBIs in community clinics. In pathway 3 (community mental health stepped care), CHWs screen patients and deliver behavioral EBIs in the community and refer medication management cases to PCPs in clinics. Mixed-methods process evaluation will be used to examine factors affecting pathway implementation, adoption, and sustainability. Clinical activities will occur without research team support. Ministry of Health personnel will coordinate training and supervision.

RESULTS

The most cost-effective pathway will be scaled up in all districts for 12 months.

NEXT STEPS

This novel study integrating comprehensive mental health services into primary care will inform a toolkit to help the Mozambican Ministry of Health scale up the most cost-effective pathway for mental health services and can be a template for other LMICs.

Reassessing the Mental Health Treatment Gap: What Happens if We Include the Impact of Traditional Healing on Mental Illness?

In this Fresh Focus, we reassess what the mental health treatment gap may mean if we consider the role of traditional healing. Based on systematic reviews, patients can use traditional healers and qualitatively report improvement from general psychological distress and symptom reduction for common mental disorders. Given these clinical implications, some high-income countries have scaled up research into traditional healing practices, while at the same time in low-and middle-income countries, where the use of traditional healers is nearly ubiquitous, considerably less research funding has studied or capitalized on this phenomena. The World Health Organization 2003-2020 Mental Health Action Plan called for government health programs to include traditional and faith healers as treatment resources to combat the low- and middle-income country treatment gap. Reflection on the work which emerged during the course of this Mental Health Action Plan revealed areas for improvement. As we embark on the next Mental Health Action Plan, we offer lessons-learned for exploring potential relationships and collaborations between traditional healing and biomedicine.

Development, Psychopathology, and Ethnicity II: Psychiatric Disorders Among Young Adults

OBJECTIVE

To estimate the prevalence of psychiatric disorders and their continuity since childhood among young adults from the same ethnic group living in 2 low-income contexts.

METHOD

Young adults (N = 2,004; ages 15-29) were followed (82.8% retention) as part of the Boricua Youth Study, a study of Puerto Rican youths recruited at ages 5-13 in the South Bronx (SBx), New York, and Puerto Rico (PR). We estimated prevalence (lifetime; past year) of major depressive (MDD), mania, hypomania, generalized anxiety (GAD), tobacco dependence, and any other substance use disorders (SUD).

RESULTS

The prevalence of every disorder was higher among young women from the SBx compared with those from PR (eg, 9.2% versus 4.1% past-year SUD; 14% versus 6.8% for MDD/GAD). Among SBx young men, tobacco dependence and illicit SUD were elevated. Across both contexts, men had higher adjusted odds of illicit SUD than women, while women had higher GAD than men. MDD did not differ by gender. Young adulthood disorders (except for alcohol use disorder and GAD) followed childhood disorders. For example, childhood externalizing disorders preceded both MDD (young men and women) and illicit SUD (young women only).

CONCLUSION

Young women raised in a context where adversities like ethnic discrimination concentrate are at high risk for psychiatric disorders. In certain high-poverty contexts, young men may present with MDD as often as women. Interventions to prevent psychiatric disorders may need to address gender-specific processes and childhood disorders. However, SUD prevention among young men may need to address other factors.

Identifying challenges and recommendations for advancing global mental health implementation research: A key informant study of the National Institute of Mental Health Scale-Up Hubs

OBJECTIVE

This study explored perspectives of researchers working with the National Institute of Mental Health (NIMH) Scale-Up Hubs, consisting of research partnerships for scaling up mental health interventions in low- and middle-income countries (LMICs), to: 1) identify common barriers to conducting impactful research on the implementation of evidence-based mental health services; and 2) provide recommendations to overcome these implementation challenges.

METHODS

A sequential qualitative approach was employed. First, an open-ended survey was distributed to the 10 Scale-Up Hubs and NIMH program staff asking informants to identify challenges in conducting mental health implementation research in LMICs. Second, survey findings guided an in-person workshop to generate implementation recommendations to inform the field.

RESULTS

In total, 46 respondents completed surveys, and 101 researchers attended the workshop. The workshop produced implementation recommendations for low-resource settings: 1) identifying impact of research on policy and practice; 2) sustaining careers of early researchers in global mental health; 3) engaging policymakers and donors to value mental health research; 4) supporting the workforce for delivering evidence-based treatments for mental disorders; and 5) promoting sustainability of programs.

CONCLUSIONS

These findings can strengthen collaboration between researchers and key stakeholders, and highlight important targets for improving mental health implementation research in LMICs.

Technology and implementation science to forge the future of evidence-based psychotherapies: the PRIDE scale-up study

OBJECTIVE

To report the interim results from the training of providers inevidence-based psychotherapies (EBPs) and use of mobile applications.

DESIGN AND SETTING

The Partnerships in Research to Implement and Disseminate Sustainable and Scalable Evidence (PRIDE) study is a cluster-randomised hybrid effectiveness-implementation trial comparing three delivery pathways for integrating comprehensive mental healthcare into primary care in Mozambique. Innovations include the use of EBPs and scaling-up of task-shifted mental health services using mobile applications.

MAIN OUTCOME MEASURES

We examined EBP training attendance, certification, knowledge and intentions to deliver each component. We collected qualitative data through rapid ethnography and focus groups. We tracked the use of the mobile applications to investigate early reach of a valid screening tool (Electronic Mental Wellness Tool) and the roll out of the EBPs PARTICIPANTS: Psychiatric technicians and primary care providers trained in the EBPs.

RESULTS

PRIDE has trained 110 EBP providers, supervisors and trainers and will train 279 community health workers in upcoming months. The trainings improved knowledge about the EBPs and trainees indicated strong intentions to deliver the EBP core components. Trained providers began using the mobile applications and appear to identify cases and provide appropriate treatment.

CONCLUSIONS

The future of EBPs requires implementation within existing systems of care with fidelity to their core evidence-based components. To sustainably address the vast mental health treatment gap globally, EBP implementation demands: expanding the mental health workforce by training existing human resources; sequential use of EBPs to comprehensively treat mental disorders and their comorbid presentations and leveraging digital screening and treatment applications.

The impact of psychiatric symptoms on condom self-efficacy among people with serious mental illness

OBJECTIVE

To determine how psychiatric symptoms affect the self-efficacy of people with serious mental illness to protect themselves and their partners from HIV and other sexually transmitted infections (STIs) by using condoms.

METHOD

As part of a National Institute of Mental Health-Funded study, people with serious mental illness (N = 467) were recruited in public psychiatric outpatient clinics in Rio de Janeiro, Brazil for an HIV prevention intervention. We examined the effects of psychiatric symptom severity on condom self-efficacy at baseline across 4 symptom clusters: affect, positive, negative, and activation.

RESULTS

Greater activation symptom severity (e.g., elated mood) was related to better condom self-efficacy, whereas greater negative symptom severity (e.g., blunted affect, emotional withdrawal) was related to worse condom self-efficacy.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our findings suggest that people living with serious mental illness who exhibit more severe negative symptoms are less likely to perceive themselves as capable of using condoms, condom negotiation, and/or condom acquisition, whereas those with more severe activation symptoms are more likely to express confidence in their capabilities. Interventions to prevent HIV and other STIs among people living with serious mental illness should take into account the effects of these symptom clusters on condom skills acquisition and perceptions of self-efficacy in carrying out needed protective behaviors. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Why place and space matter for intimate partner violence survivors' mental wellbeing and communities in Northeastern Uganda

The context of place matters for mental health. Employing a feminist framework, this study used key informant interviews and focus group discussions in May 2012 with 77 conflict-affected adults, children, and adolescents in Northeastern Uganda to understand the relation of place and the symbolic space of family to IPV survivors' mental wellbeing to shape intervention possibilities. Using Grounded Theory methods, narratives identified numerous negative mental health experiences, such as having a disturbed mind, associated with inhabiting a violent domestic space. Place-associated qualities interacted with the symbolic space of the family to impede women's ability to enhance the safety of their domestic space, discourage separation, and encourage reunification in the case of separation, all of which related to negative mental health experiences. Interventions should not assume that IPV survivors' exposure to violence has terminated and look beyond mental health as an individual outcome.

Returning to work after fatigue treatment and counseling in HIV/AIDS

BACKGROUND

Employment rates for people with HIV/AIDS are low, compared to the general population. One widespread barrier is fatigue, accompanied by daytime sleepiness and a lack of stamina. Previous pharmacological studies have demonstrated improvement of fatigue-related symptoms without affecting work-related goal attainmentOBJECTIVE:In this pilot study, we sought to determine whether a pharmacologic-behavioral two-phase combined approach could facilitate returning to work.

METHODS

HIV+ participants with fatigue were treated with armodafinil. If energy improved, 8 sessions of biweekly manualized Behavioral Activation (BA) counseling were added to medication maintenance. Outcome was assessed on a 3-point scale along with clinician and self-ratings.

RESULTS

Of the 46 participants enrolled in BA, 15 (33%) did not complete all 8 sessions: 6 got jobs so they no longer needed counseling; 4 did not like BA, and 5 dropped out for reasons such as moving away or substance use relapse. Of the 46, 29 (63%) attained their vocational goal and showed significant changes on self-report scales.

CONCLUSIONS

Our integrated treatment including armodafinil plus BA counseling significantly increased the success of achieving work-related goals. The two-phase medication plus counseling program was well-tolerated by participants and the manualized BA counseling was readily applied by counselors without advanced mental health training, making the method potentially feasible in community settings.

Improving estimation of the association between alcohol use and intimate partner violence in low-income and middle-income countries

BACKGROUND

Alcohol use is a consistent correlate of intimate partner violence (IPV) in low-income and middle-income countries (LMICs). However, the magnitude of this association differs across studies, which may be due to contextual and methodological factors. This study aims to estimate and explore sources of heterogeneity in the association between alcohol use and IPV in 28 LMICs (n=109 700 couples).

METHODS

In nationally representative surveys, partnered women reported on IPV victimisation and male partner's alcohol use. We estimated the relationship between alcohol use and IPV using logistic regression and full propensity score matching to account for confounding. Country-specific ORs were combined using a random-effects model. Country-level indicators of health and development were regressed on ORs to examine sources of variability in these estimates.

RESULTS

Partner alcohol use was associated with a 2.55-fold increase in the odds of past-year IPV victimisation (95% CI 2.27 to 2.86) with substantial variability between regions (I2=70.0%). Countries with a low (<50%) prevalence of past-year alcohol use among men displayed larger associations between alcohol use and IPV. Exploratory analyses revealed that colonisation history, religion, female literacy levels and substance use treatment availability may explain some of the remaining heterogeneity observed in the strength of the association between alcohol use and IPV across countries.

CONCLUSION

Partner alcohol use is associated with increased odds of IPV victimisation in LMICs, but to varying degrees across countries. Prevalences of male alcohol use and cultural factors were related to heterogeneity in these estimates between countries.

Integrating tuberculosis and mental health services: global receptivity of national tuberculosis program directors

<sec id="st1"> <title>SETTING</title> A global survey of National Tuberculosis Program (NTP) directors. </sec> <sec id="st2"> <title>OBJECTIVES</title> To assess the perceived mental health needs of persons with tuberculosis (TB), current practices, and receptivity to integrating evidence-based mental and substance use treatment into national TB guidelines. </sec> <sec id="st3"> <title>DESIGN</title> Semi-structured survey of NTP directors from 26 countries of all income levels using a standardized questionnaire. </sec> <sec id="st4"> <title>RESULTS</title> Of the 26 countries, 21 were classified as high incidence and/or burden countries for TB, TB and human immunodeficiency virus coinfection, and/or drug-resistant TB. Two NTPs included routine screening for any mental disorder, four assessed alcohol or drug use, and five had standard protocols for the co-management of disorders. If effective and low-cost integrated care models were available, 17 NTP directors felt that it was highly likely, and five somewhat likely, that their NTPs would integrate mental health treatment into national TB guidelines and services. The main perceived barriers to service integration were limited capacity, not recognizing mental health as a problem, insufficient resources, and TB-related social stigma. </sec> <sec id="st5"> <title>CONCLUSIONS</title> NTPs currently do not address mental disorders as part of routine practice. Nevertheless, receptivity is high, which creates a ripe opportunity to integrate the management of TB and mental disorders into the policies and guidelines of NTPs worldwide. </sec>.

Violence against children and intimate partner violence against women: overlap and common contributing factors among caregiver-adolescent dyads

BACKGROUND

Intimate partner violence against women (IPV) and violence against children (VAC) are both global epidemics with long-term health consequences. The vast majority of research to date focuses on either IPV or VAC, however the intersections between these types of violence are a growing area of global attention. A significant need exists for empirical research on the overlap of IPV and VAC, especially in contexts with particularly high rates of both types of violence.

METHODS

This exploratory study includes secondary analysis of data from a cluster randomized controlled trial in Ugandan schools. Using baseline reports from a random sample of early adolescents attending school and their caregivers, this study uses a probability sample across all eligible schools of adolescent-caregiver dyads (n = 535). We categorized adolescent-caregiver dyads into four groups: those reporting VAC 'only', IPV 'only', both VAC and IPV, or 'no violence'. Two separate multinomial logistic regression models for male and female caregivers explored adolescent and caregiver characteristics associated with the VAC 'only', the IPV 'only', or the both VAC and IPV dyads, each compared to the 'no violence' dyad.

RESULTS

One third of dyads reported both IPV and VAC and nearly 75% of dyads reported VAC or IPV. Dyads reporting IPV were more likely to also report VAC. Common contributing factors for female caregiver-adolescent dyads with both VAC and IPV include lower SES, less caregiver education, higher caregiver mental distress, more frequent caregiver alcohol use, and caregivers who report less emotional attachment to their intimate partner. Male caregiver-adolescent dyads with both VAC and IPV included caregivers with less emotional attachment to their intimate partner and more attitudes accepting VAC.

CONCLUSIONS

Findings reveal a significant overlap of IPV and VAC and the importance for violence prevention and response programming to consider coordinated or integrated programming. Unique results for female and male caregivers highlight the importance of a gendered approach to addressing IPV and VAC intersections.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov, NCT01678846, on September 5, 2012.

Violence against children and intimate partner violence against women: overlap and common contributing factors among caregiver-adolescent dyads

BACKGROUND

Intimate partner violence against women (IPV) and violence against children (VAC) are both global epidemics with long-term health consequences. The vast majority of research to date focuses on either IPV or VAC, however the intersections between these types of violence are a growing area of global attention. A significant need exists for empirical research on the overlap of IPV and VAC, especially in contexts with particularly high rates of both types of violence.

METHODS

This exploratory study includes secondary analysis of data from a cluster randomized controlled trial in Ugandan schools. Using baseline reports from a random sample of early adolescents attending school and their caregivers, this study uses a probability sample across all eligible schools of adolescent-caregiver dyads (n = 535). We categorized adolescent-caregiver dyads into four groups: those reporting VAC 'only', IPV 'only', both VAC and IPV, or 'no violence'. Two separate multinomial logistic regression models for male and female caregivers explored adolescent and caregiver characteristics associated with the VAC 'only', the IPV 'only', or the both VAC and IPV dyads, each compared to the 'no violence' dyad.

RESULTS

One third of dyads reported both IPV and VAC and nearly 75% of dyads reported VAC or IPV. Dyads reporting IPV were more likely to also report VAC. Common contributing factors for female caregiver-adolescent dyads with both VAC and IPV include lower SES, less caregiver education, higher caregiver mental distress, more frequent caregiver alcohol use, and caregivers who report less emotional attachment to their intimate partner. Male caregiver-adolescent dyads with both VAC and IPV included caregivers with less emotional attachment to their intimate partner and more attitudes accepting VAC.

CONCLUSIONS

Findings reveal a significant overlap of IPV and VAC and the importance for violence prevention and response programming to consider coordinated or integrated programming. Unique results for female and male caregivers highlight the importance of a gendered approach to addressing IPV and VAC intersections.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov, NCT01678846, on September 5, 2012.

Challenges and opportunities in the science of research to practice: lessons learned from a randomized controlled trial of a sexual risk-reduction intervention for psychiatric patients in a public mental health system

Objective:

Human immunodeficiency virus (HIV) prevention efficacy trials with psychiatric patients have been conducted in research settings in high-resourced countries, establishing short-term efficacy for reducing sexual risk behavior. None has been implemented within systems of care. In the last decade, overcoming this research-to-practice gap has become a focus of implementation science. This paper describes the first and only HIV Prevention intervention trial for psychiatric patients conducted in real-world outpatient psychiatric settings facilitated by trained clinic-based providers.

Methods:

The HIV Prevention intervention, which uses the Information-Motivation-Behavioral Skills model to achieve sexual risk-reduction, was rigorously adapted to the local context and clinic services’ needs. Participants from eight clinics were randomized to HIV Prevention or Health Promotion conditions.

Results:

HIV Prevention participants showed significant improvement in Information-Motivation-Behavioral domains; in this group, behavioral intentions were associated with significantly fewer unprotected sex occasions, but reduction of unprotected sex occasions was similar in both conditions.

Conclusion:

Our trial was conducted before implementation studies became widely funded. Transporting an intervention to a new culture or into real-world practice settings may require adaptations. Our results demonstrate that clear guidelines are needed regarding whether to conduct efficacy, effectiveness, and/or implementation research as the most appropriate next step.

Clinical trial registration:

NCT00881699

Acceptability of electronic healthcare predictive analytics for HIV prevention: a qualitative study with men who have sex with men in New York City

BACKGROUND

Large data sets, also known as "big data", shared in health information exchanges (HIEs), can be used in novel ways to advance health, including among communities at risk for HIV infection. We examined values and opinions about the acceptability of using electronic healthcare predictive analytics (eHPA) to promote HIV prevention in men who have sex with men (MSM). Our aims were twofold: (I) to evaluate the perspectives of MSM with diverse race/ethnicity and age on the acceptability of predictive analytics to determine individual HIV risk and (II) to determine acceptability of having targeted prevention messaging based upon those risk estimates sent directly to the consumer.Method: Two of the authors facilitated 12 focus groups (n=57) with adult MSM without HIV, living in NYC. Groups were divided by ethnicity (Black, Latino, and White) and age (under 35 and 35 and over). Participants were recruited through HIV prevention sites, community-based organizations, social media, and Internet sites that serve these communities. Grounded theory methods were used to analyze the data with Dedoose.

RESULTS

We identified six main themes related to acceptability: (I) reach, relevance, and potential uptake of using predictive analytics to establish HIV risk and deliver targeted prevention messaging; (II) patient-provider communication; (III) public health and individual rights; (IV) perceptions of intervention effectiveness; (V) electronic health data security; and (VI) stigma. Within each thematic domain, MSM discussed concerns, benefits, and provided recommendations for implementation.

CONCLUSIONS

MSM in this study were supportive of the use of "big data" and technology to reach marginalized populations and improve public health, yet expressed concerns about the relevance, effectiveness, and security eHPA. Efforts to advance eHPA for HIV prevention should address these concerns, especially among the most-at-risk communities of color. Development of eHPA for HIV prevention should involve targeted messaging that addresses specific concerns regarding eHPA security, accuracy, and relevance.

Supporting the well-being of health care providers during the COVID-19 pandemic: The CopeColumbia response

OBJECTIVE

COVID-19 is an international public health crisis, putting substantial burden on medical centers and increasing the psychological toll on health care workers (HCW).

METHODS

This paper describes CopeColumbia, a peer support program developed by faculty in a large urban medical center's Department of Psychiatry to support emotional well-being and enhance the professional resilience of HCW.

RESULTS

Grounded in evidence-based clinical practice and research, peer support was offered in three formats: groups, individual sessions, and town halls. Also, psychoeducational resources were centralized on a website. A Facilitator's Guide informed group and individual work by including: (1) emotional themes likely to arise (e.g., stress, anxiety, trauma, grief, and anger) and (2) suggested facilitator responses and interventions, drawing upon evidence-based principles from peer support, stress and coping models, and problem-solving, cognitive behavioral, and acceptance and commitment therapies. Feedback from group sessions was overwhelmingly positive. Approximately 1/3 of individual sessions led to treatment referrals.

CONCLUSIONS

Lessons learned include: (1) there is likely an ongoing need for both well-being programs and linkages to mental health services for HCW, (2) the workforce with proper support, will emerge emotionally resilient, and (3) organizational support for programs like CopeColumbia is critical for sustainability.

Armed Conflict, Intimate Partner Violence, and Mental Distress of Women in Northeastern Uganda: A Mixed Methods Study

As global mental health research and programming proliferate, research that prioritizes women's voices and examines marginalized women's mental health outcomes in relation to exposure to violence at community and relational levels of the socioecological model is needed. In a mixed methods, transnational study, we examined armed conflict exposure, intimate partner violence (IPV), and depressive symptoms among 605 women in Northeastern Uganda. We used analysis of variance to test between groups of women who had experienced no IPV or armed conflict, IPV only, armed conflict only, and both; and linear regression to predict depressive symptoms. We used rapid ethnographic methods with a subsample (n = 21) to identify problem prioritization; and, to characterize women's mental health experiences, we conducted follow up in-depth interviews (n = 15), which we analyzed with grounded theory methods. Thirty percent of the sample met the cut-off for probable major depressive disorder; women exposed to both IPV and armed conflict had significantly higher rates of depression than all other groups. While women attributed psychological symptoms primarily to IPV exposure, both past-year IPV and exposure to armed conflict were significantly associated with depressive symptoms. Women identified socioeconomic neglect as having the most impact and described three interrelated mental health experiences that contribute to thoughts of escape, including escape through suicide. Policy efforts should be interprofessional, and specialists should collaborate to advance multi-pronged interventions and gender-informed implementation strategies for women's wellbeing.

Limited Knowledge and Lack of Screening for Acute HIV Infection at Primary Care Clinics in High-Prevalence Communities of New York City

Diagnosis and treatment of acute HIV infection (AHI) is crucial for ending the HIV epidemic. Individuals with AHI, who have high viral loads and often are unaware of their infection, are more likely to transmit HIV to others than those with chronic infection. In preparation for an educational intervention on AHI in primary health care settings in high HIV-prevalence areas of New York City, 22 clinic directors, 313 clinic providers, and 220 patients were surveyed on their knowledge and awareness of the topic from 2012-2015. Basic HIV knowledge was high among all groups while knowledge of AHI was partial among providers and virtually absent among patients. Inadequate knowledge about this crucial phase of HIV may be impeding timely identification of cases in the primary care setting.

Retention in HIV Care in Australia: The Perspectives of Clinicians and Clients, and the Impact of Medical and Psychosocial Comorbidity

Significant advances in our understanding and treatment of HIV have led to improvements in the medical management of the illness, as HIV infection has evolved from an acute to a chronic illness. Increasing our understanding of the medical and/or psychosocial comorbidities, which can interact to determine "clinical complexity" and impact HIV management, will further strengthen this process. Retention in care is a critical step of the HIV Treatment Cascade, which facilitates effective management of these comorbidities and their impact on HIV medical management. This study sought to build on literature regarding medical and/or psychosocial comorbidity that impacts retention in care, and it often leads to clinically complex presentations, by gaining the perspectives of people living with HIV (PLHIV), and medical and allied health clinicians in the field in Sydney, Australia. A total of 16 clinicians (medical doctors, nurses, clinical psychologists, and social workers) and 14 clients participated in a series of focus groups; they were asked to comment on the perceived barriers to retention and the potential solutions to overcome these. The results indicated a significant degree of overlap between clinician and client perspectives, and they identified "service-specific factors," "logistic/practical factors," "medical/physical factors," and "psychosocial factors" as potential barriers to retention. Results are reviewed in the context of similarities and differences in perspectives between clinicians and PLHIV, and limitations regarding the generalizability of findings are discussed. The broader context of comorbidity and clinical complexity is also examined.