Zimbaweans living with HIV also suffer from post-traumatic stress order (PTSD), often because of stigma, and are in desperate need of dedicated mental health services to help them cope. This is one of the findings of a recent new study at Stellenbosch University (SU) in South Africa.
“In Zimbabwe, the term common mental disorders, which includes depression and anxiety, has traditionally excluded a focus on PTSD despite earlier work suggesting that PTSD-like symptoms are prevalent among those living with HIV,” says Dr Ruth Verhey, a Consultant Clinical Psychologist involved with the Friendship Bench Initiative in Zimbabwe. Verhey obtained her doctorate in Psychiatry on Tuesday (11 December 2018) at SU’s second graduation ceremony of December 2018.
Highlighting the prevalence of PTSD among people living with HIV in low- and middle-income countries such as Zimbabwe and South Africa, Verhey says the aim of her doctoral study was to ascertain what additional intervention aspects could be added to the Friendship Bench programme in Zimbabwe to address the symptoms of trauma.
“Very few studies have focused on effective treatments for PTSD in people living with HIV despite its high prevalence. In Zimbabwe, PTSD has been underdiagnosed because resources are scarce and it has not been seen as a major public health threat. Also, the Friendship Bench Initiative, which has been running for more than 10 years, focuses on lowering depression and anxiety.”
Delivered by community health workers, the Friendship Bench provides a crucial mental health service given the few mental health professionals in Zimbabwe. It has been scaled up to over 70 primary health care facilities in the country.
Verhey says sessions between community health workers (i.e. community members with task-related training but no formal professional qualifications) and those affected, are held on a bench in a discrete area on the clinic premises and allows for an acceptable level of confidentiality.
She adds that her study confirmed previous research that people living with HIV make up more than 50% of the Friendship Bench clients.
“This highlights the need to integrate aspects of PTSD management within care packages for common mental disorders delivered by community health workers.”
“Understanding the magnitude of depression and anxiety in people living with HIV, and factors associated with trauma and PTSD and the experience of community health workers working with this population are all crucial precursors to developing a strategy for integrating a care package for PTSD within the existing Friendship Bench programme.”
As part of her study, Verhey surveyed 204 adult patients and 182 community health workers and also interviewed 10 patients and 5 community health workers. Of the 204 patients who participated in the survey, 91 (44.6%) were HIV positive.
“My study found that 40.7% of these 204 patients have PTSD, and of those 69.5% also had common mental disorders. Among those living with HIV, 42 (46.2%) had PTSD.”
“Many clients described traumatic effects related to their HIV-infection. Some of the factors include physical illness, domestic violence, and the reaction of the wider community and family to their displaying symptoms of ‘the illness’.”
“Faced by numerous socio-economic challenges such as unemployment, an ailing health system and an ongoing HIV epidemic fuelled by extreme stigma, Zimbabweans living with HIV experience the condition as an ongoing pervasive threat to their survival.”
According to Verhey, it is important for an initiative like the Friendship Bench to address PTSD in people living with HIV because the lack of self-care resulting from PSTD can mean they default on medication which is dangerous, especially in areas where there is not much chance for changing to a different antiretroviral treatment.
Community health workers
As regards community health workers’ knowledge of HIV-related PSTD, Verhey says the interviews revealed that they had an understanding of the concept of traumatic experiences as an ‘unknown’ illness related to being diagnosed with HIV and being stigmatized. She adds that they had a clear understanding of what traumatic stressors are and how they affect a person.
“Although community health workers working on the Friendship Bench were not aware of PTSD as described in the Diagnostic and Statistical Manual of Mental Disorders, they were still able to capture salient features of the condition, such as avoidance, re-experiencing (i.e. flashbacks), hyper-arousal and negative thought patterns such as self-blame.”
“With no prior knowledge of PTSD, they coined this phenomenon as ‘kufungisisa kwenjodzi’ (thinking excessively due to trauma). Through the lens of ‘kufungisisa kwenjodzi’ they have managed to incorporate their clients’ reports of traumatic experiences (‘njodzi’) into the existing common mental disorders by treating it as a more severe form of ‘kufungisisa’ (thinking too much).”
Verhey points out that even though community health workers were being exposed to the same stressors as their clients such as poverty, HIV infection and other chronic conditions, lack of access to medical treatment, loss of loved ones, displacement and violence, the rate of PSTD among them was low.
“I found a very low PTSD rate of 6% amongst the 182 community health workers, and 11% scored above the cut-off for common mental disorders.” Verhey says community health workers should receive regular supervision, clear referral pathways, debriefing, acceptable remuneration and ongoing education to avoid them becoming over-stretched.
“We’re working on an ongoing education programme that will help them recognize and focus on the symptoms of PTSD.”
Verhey says the findings of this study are applicable to people in similar settings as those in Zimbabwe, adding that the Friendship Bench programme has been expanded to Malawi and Zanzibar/Tanzania as well as New York City.