OJNOpen Journal of Nursing2162-5336Scientific Research Publishing10.4236/ojn.2015.53023OJN-54666ReviewMedicine&Healthcare Mental Health Problems Affecting People Who Have HIV and AIDS in Malawi: A Review enesisChorwe-Sungani1*AnthonySefasi1MercyPindani1Community and Mental Health Nursing Department, University of Malawi, Blantyre, Malawi* E-mail:genesischorwe@kcn.unima.mw(EC);06032015050318919425 February 2015accepted 12 March 16 March 2015© Copyright 2014 by authors and Scientific Research Publishing Inc. 2014This work is licensed under the Creative Commons Attribution International License (CC BY). http://creativecommons.org/licenses/by/4.0/

Malawi is located in the southern part of Africa with a population of more than 16 million people. The country is ravaged with HIV and AIDS epidemic of which the prevalence rate is at 14%. The people who have HIV/AIDS are also affected by mental and psychological disorders. Nevertheless, very little is known about mental health care of people who have HIV and AIDS in Malawi. We did literature search using AJOL, Proquest, PsychINFO, Google Scholar and HINARI search engines and the search yielded scanty (12) research studies on the mental health of people with HIV and AIDS that were conducted in Malawi between 2006-2014. Twelve (12) studies that were reviewed focused on prevalence of mental disorders among people who have HIV and AIDS; nurses’ knowledge and skills for providing mental health care to people living with HIV and AIDS (PLWHA); perceived risk of HIV infection among people who have mental health problems; substance abuse and HIV/AIDS issues and awareness of interaction between HIV/AIDS and Mental health. In conclusion, the review shows that people with HIV infection are also affected by mental health problems such as depression and substance abuse. They receive some mental health care in general settings at ART clinics because mental health care is integrated into general health care delivery system. Therefore, it is necessary that health professionals who are generalists should be equipped with adequate knowledge and skills for providing mental health care to care to people with HIV and AIDS.

Mental Health Care HIV and AIDS Mental Disorders1. Introduction

Malawi is located in the southern part of Africa. The country has an estimated population of more than 16 million people. The majority of these people (80%) live in rural areas and survive on less than a dollar per day. The country is ravaged with HIV and AIDS epidemic of which the prevalence rate is at 14% [1] . The people who have HIV/AIDS in Malawi like elsewhere are also affected by mental and psychological disorders [2] -[5] . Mental health and HIV and AIDS are interlinked such that mental disorders are associated with increased risk of HIV infection and AIDS and interfere with their treatment, and on the other hand some mental disorders occur as a direct result of HIV infection [1] . Despite the fact that mental health and HIV and AIDS are linked, very little is documented about mental health problems that affect people who have HIV and AIDS in Malawi. The delivery of mental health care to people who have HIV and AIDS is important because apart from the physical illnesses associated with the virus, these people are also affected by mental disorders [6] -[9] . Hence HIV and AIDS intervention programmes must include mental health care if they are going to be successful [7] . Providing mental health care to PLWHA may be helpful in preventing further spread of the infection and improving the quality of life of those affected [10] .

2. Methods

We utilsed AJOL, PsychINFO, Proquest, Google Scholar and HINARI search engines to look for articles using combinations of the following search terms: Malawi AND HIV and AIDS mental disorders, mental illness, mental health, anxiety disorders, mood disorders, adjustment disorders, schizophrenia and psychosis, mental health care and psychiatric disorders. The search yielded scanty (12) research studies in English language that were conducted in Malawi. We also searched for the references cited in relevant studies. We reviewed studies that were published from 2006-2014 that focused on the mental health of people with HIV and AIDS in Malawi. These studies included quantitative and qualitative studies. We did not find any study that was published before 2006.

3. Results

Twelve (12) studies were reviewed. Four studies reported on prevalence mental disorders among people who have HIV and AIDS. Three studies reported about nurse’s provision of mental health care to PLWHA in Blantyre district. Another study looked at perceived risk of HIV infection among people who have mental health problems. Three studies examined the substance abuse and HIV/AIDS issues. One study looked at youth awareness of interaction between HIV/AIDS and Mental health. The detailed results are presented in table 1.

4. Discussion4.1. Common mental health problems affecting people Who have HIV and AIDS

We found that there are very few studies that were conducted to investigate prevalence of mental disorders among people who have HIV infection in Malawi. We reviewed only four studies that had investigated the magnitude and nature of mental disorders that affect people who have HIV and AIDS in the country. It is clear that people with HIV and AIDS are also affected with various forms of mental disorders [11] . A study that was conducted among HIV positive people who were attending Antiretroviral Therapy (ART) clinics in Mzuzu found 14.4% as a prevalence rate of psychological distress among these people [4] . Similar studies have indicated that almost half of people who have HIV and AIDS in Africa suffer from some form of mental disorder, commonly depression [2] . This is true for Malawi where a study that was conducted among mothers of infants in Malawi, found that depression and anxiety are associated with HIV infection [12] . We also discovered that the prevalence of substance use among people with HIV/AIDS in Malawi is high. For instance, one study revealed that 25.5% of cannabis (chamba) and alcohol abusers were HIV positive in the country [13] . But worthy noting is that there are no studies that have been conducted to elucidate the prevalence of psychotic disorders among HIV positive people in Malawi. However, studies that were conducted elsewhere show that the prevalence of psychotic disorders among people with HIV infection ranges from 3% to 23% [14] . This is a call for concern because the utilization of HIV-services among psychiatric patients is low in some parts of Malawi [15] and their condition may lead to HIV treatment nonadherence. Therefore, more studies should be conducted to explore the prevalence of psychosis and other mental disorders among people with HIV infection across the country. The findings of such studies will help in informing the HIV and AIDS interventions targeting people with mental disorders which are being implemented across Malawi. It is evident that the individual’s perceived risk of infec-

Summary of studies that were conducted in Malawi on mental health and HIV/AIDS
AuthorStudy siteSamplesStudy designMain findings
Bisika et al., (2008)Thyolo District HospitalN = 200 men and women who abuse drugsDescriptive surveyOverall prevalence rate for HIV was 25.5% 81.3% were abusing cannabis (Chamba) 18.3% were abusing and alcohol 25.5% of participants who abused cannabis were HIV-positive 31.1%, of alcohol abusers were HIV positive
Chorwe- Sungani (2013)Blantyre DistrictN = 109 nursesDescriptive quantitative survey adapted Mental Health Problems Perception Questionnaire (MHPPQ)Nurses lack knowledge and skills for providing mental health care to people with HIV and AIDS 53.2%, lacked knowledge and skills to care for people living with HIV and AIDS who have mental health problems
Chorwe- Sungani & Shangase (2013)Blantyre DistrictN = 136 nursesDescriptive quantitative survey adapted Mental Health Problems Perception Questionnaire (MHPPQ)Study findings revealed that there is a linear relationship between general nurses’ levels of knowledge and skills and their therapeutic commitment(r = 0.40, n = 136, p = 0.05) to provide mental health care of people living with HIV/AIDS 45.6% of the participants reported that they did not want to work with people with mental health problems who have HIV/AIDS
Chorwe- Sungani, Shangase & Chilinda (2014)Blantyre DistrictN = 109 nursesDescriptive quantitative survey adapted Mental Health Problems Perception Questionnaire (MHPPQ)Most of the general nurses do not feel confident about caring for people with HIV/AIDS who have mental health problems and the nurses do not always receive the support they need 64.2% of participants reported that they do not feel comfortable when caring for people with mental health problems who have HIV/AIDS
Hsieh (2013)Rumphi, Mchinji and Balaka DistrictsN = 2606 ever-married women aged between 15 and 49years (1541) and their spouses (1065)Longitudinal studyMental health and the perceived risk of HIV infection are negatively correlated (r = −0.19, p < 0.05). HIV perception has a significant influence on emotional/affective well-being The perceived risk of infection has a strong negative relationship with mental health outcomes
Jere et al., (2013)Ntcheu District18 key leaders 15 young men Systematic observation of the market place and surrounding establishmentsQualitative ethnographic studyThere were three patterns among young men Alcohol and marijuana were two substances commonly used by young men Substance use was linked to sex with multiple partners and irregular use of condoms
Jere et al., (2012)NtcheuFocus group data from 10 rural villages 3 focus groups in young men (10 - 19 years) Focus group discussion: 6 female youths and 11 adults (5 male, 6 female)Content analysis using constant comparative method guided by ecological perspectiveYoung men engaged in alcohol use and risky behaviours despite availability of condoms Young men perceived a direct link between alcohol and unsafe sexual practices
John- Langba et al., (2006)MalawiN = 3800 adolescents (12 - 19 year olds)SurveyUse of alcohol and other substances are associated with risky sexual behaviors and especially with multiple sexual partnerships and limited use of condoms 68% of sexually active adolescents that have ever drank alcohol in Malawi did not use condoms during their last sexual intercourse with a most recent partner 74% of adolescents that had ever used a mood altering drug in Malawi did not use a condom during their last sexual intercourse
Kim et al., (2013)Antiretroviral Clinics in Central and Southern MalawiN = 562 adolescents (female and male)Cross-sectional design Beck’s Depression Inventory-II (BDI-II), Childrens’s Depression Inventory-2 (CDI-2) and Children’s Depression Rating Scale-Revised (CDRS-R)There is high prevalence of depression among HIV infected adolescents in Malawi. BDI-II: 25.6% with depression CDI-2: 20.8% with depression CDRS-R: 18.9 with depression
Lommerse et al., 2013ThyoloN = 174 patients with neuropsychiatric disordersDescriptive cross-sectional studyOverall HIV prevalence was 14.8%. HIV-prevalence among participants with psychiatric conditions was 17.7% HIV-prevalence among participants with epilepsy was 12.8% The uptake of HIV-services among HIV-positive patients was low ・ 35% of HIV positive patients did not use recommended prophylactic therapy ・ 44% of HIV positive patients were not receiving antiretroviral treatment (ART) had never been assessed for ART eligibility Overall sexual activity rate was 61%, and 9% of sexually active participants had multiple partners. 89% did not use condoms consistently with stable sexual partners 79% did not use condoms consistently with occasional >50% patients did not know HIV status of their sexual partners
Mwale et al., (2007)Mzuzu Central Hospital and St. Johns Hospital in Mzuzu AntiRetroviral ClinicsN = 440 men and womenCross-sectional surveyPsychological distress among people living with HIV and AIDS go undiagnosed in ARV clinics 14.4% with psychological distress and 4.5% with suicidal feelings
Wright et al., 2007Zomba District12 existing groups of secondary school students, orphans and vulnerable children, teenage mothers, and out-of-school youths 6 to 9 participants per group aged between 14 and 20 yearsExploratory studyRespondents demonstrated awareness of a link between mental health concerns and HIV HIV/AIDS was seen as having psychological impact on mental health of young people HIV or AIDS was identified as one of the reasons for a character’s trauma

tion with HIV negatively influences mental health outcomes [16] . Health workers should endeavour to deal with individuals’ misperceptions of their HIV status as a way of promoting mental health.

Three studies that we reviewed indicated that some people who abuse psycho active substances are also affected with HIV and AIDS. One study found that for HIV prevalence rate among people who abuse drugs and alcohol was 25.5% [13] . The commonly abused substances were cannabis (81.3%) and alcohol (18.3%). These commonly abused substances are usually cheaper and easily accessed by the abusers in Malawi. Substance abuse is associated with HIV and AIDS such that behaviors related to drug abuse are some of the major factors that increase the spread of HIV infection [13] . It is a of public health concern that one study found that young men in the country who abuse alcohol engaged in risky sexual behaviours [17] . This is corroborated by John-Langba and colleagues [18] who found that many adolescents in Malawi have ever used alcohol (68%) or drugs (74%) and did not use condom during their last sexual intercourse. This shows that drug and alcohol use are some of the factors fuelling the spread of HIV infection among the youths. Hence we suggest that HIV interventions targeting the youths and other population groups in the country should also include the aspect of drug and alcohol abuse since there is a direct link between alcohol and unsafe sexual practices.

4.2. Provision of mental health care to people with HIV Infection

In Malawi, mental health services are integrated into the general health care delivery system so that people can access the services at Central Hospitals, District Hospitals, Community Hospitals, Health Centres and Outreach. This means that people living with HIV and AIDS can access mental health care in general settings at Anti Retroviral Clinics. Nurses, Clinical Officers, Medical Assistants and Physicians who have not specialized in mental health attend to mental health problems of these people. This helps in reducing the patients’ burden of moving from place to place to get services they need. However, it is documented that most health workers in Malawi feel neither confident nor competent when dealing with the mental disorders of their clients [19] [20] . This is corroborated by Chorwe-Sungani who found that that more than half of the nurses (53.2%) did not have knowledge and skills to care for people with co-morbidity of HIV and AIDS and mental disorders[21] . This implies that people with co-morbidity of HIV infection and mental disorders do not always access appropriate mental health care in general settings. Consequently, many of these people end up being referred to mental hospitals which are far away from their homes.

In Malawi there is one government mental hospital and another one run by missionaries [21] . There are inadequate mental health specialists to serve about 16 million people [22] . The country is served by one Psychiatrist; 29 psychiatric clinical officers; 233 psychiatric nurses in Malawi; 2 social workers; 3 Occupational therapists; and 5 Psychologists working in public health sector. These health professionals provide specialized mental health care to people living with HIV and ADIS who have mental disorders. But it is clear that mental health professionals are not adequate and this poses a serious challenge in the provision of mental health care to people with HIV infection and the entire population. Therefore, it is right and proper that in this situation where mental health specialists are few, they should be deployed appropriately and non-specialised health professionals are equipped with relevant knowledge and skills through ongoing in-service mental health education and support from mental health specialists. This will help the health professionals to be competent enough to ably provide mental health care to people with HIV infection across the country. It is clear that nurses who perceive themselves as having adequate knowledge and skills for dealing with mental health problems are more likely to be willing to provide mental health care to people living with HIV/AIDS [23] .

5. Conclusion

The review shows that people with HIV infection are also affected by mental health problems such as depression and substance abuse. They receive some mental health care in general settings at ART clinics because mental health care is integrated into general health care delivery system. Therefore, it is necessary that health professionals who are generalists should be equipped with adequate knowledge and skills for providing mental health care to care to people with HIV and AIDS.

Acknowledgements

We thank all those who assisted us during literature search.

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