Strengthening the Integration of Mental Health and HIV Services in South Africa: Implementation Science in Support of Scale-Up, Adaptation, and Dissemination

摘要 南非艾滋病毒和精神疾病并存的负担令人震惊：19%的南非人 艾滋病毒感染者中有14-30%患有常见的精神障碍。只有25%的人收到 任何形式的心理治疗。常见的精神障碍与艾滋病毒共病威胁的有效性 艾滋病治疗和携带有害的耻辱。将精神疾病护理纳入艾滋病毒相关服务， 解决这些污名、缩小治疗差距和改善治疗结果的潜力。集成 服务在南非显示出有效性，但成功的障碍和促进因素 执行情况仍然没有确定。这个多学科的项目受益于及时的合作，丰富的 在心理健康和艾滋病毒/艾滋病的交叉点，多年的经验，并适用于 科学的执行方法，以加强综合精神卫生和艾滋病毒的执行， 南非的相关服务。本研究应用了实施研究的综合框架 确定并解释与这些问题相关的干预和提供者层面的障碍和促进因素， 作为艾滋病毒和精神卫生综合服务的一部分， 南非它将通过结合问卷调查， 和访谈数据收集的护士与现有的二手资料，从例行程序监测。这 这项研究以三个正在进行的项目的成果和资源为基础。国际发展部资助的 改善精神卫生保健（PRIME）项目和NIH资助的实用集群随机对照 共病情感障碍、艾滋病/艾滋病毒和长期健康（COBALT）试验正在检查 在北部两个地区的一个卫生设施子集中提供综合心理健康和艾滋病毒服务的情况和影响 南非西部省。与此同时，由疾病预防控制中心资助的华盛顿大学的一项合作， TECH南非，和夸祖鲁-纳塔尔大学正在加强这些努力，并扩大到两个新的 区。通过利用这些项目，并对可靠的定量和定性数据进行三角测量，本研究将 解决与成功整合心理健康相关因素的知识方面的关键差距 艾滋病服务。这将是第一个应用严格的实施科学框架的研究 研究，包括成功执行的预测因素的有效措施， 在低资源环境下整合心理健康和艾滋病毒服务的进程。此外，评估 这些障碍和促进因素将直接导致改进在南非推广的方法， 改善规模扩大和随后的患者结果。

Abstract The burden of co-morbid HIV and mental illness in South Africa is staggering: 19% percent of South Africans live with HIV, and 14-30% of people living with HIV suffer from common mental disorders. Only 25% receive mental health treatment of any kind. Common mental disorders co-morbid with HIV threaten the effectiveness of HIV treatment and carry damaging stigmas. Integrating care for mental illness into HIV-related services has the potential to address these stigmas, reduce treatment gaps, and improve treatment outcomes. Integrated services are demonstrating effectiveness in South Africa, yet the barriers to and facilitators of successful implementation remain undefined. This multi-disciplinary project benefits from a timely collaboration, rich with many combined years of experience at the intersection of mental health and HIV/AIDS, and applies the methods of implementation science to strengthen the implementation of integrated mental health and HIV- related services in South Africa. This study applies the Consolidated Framework for Implementation Research to identify and explain the intervention- and provider-level barriers and facilitators that are associated with the successful screening and referral of patients by nurses as part of integrated HIV and mental health services in South Africa. It will gain a holistic understanding of the challenges of integration by combining questionnaire and interview data collected from nurses with available secondary data from routine program monitoring. This study builds on the results and resources of three ongoing projects. The DFID-funded Programme for Improving Mental Health Care (PRIME) project and NIH-funded pragmatic cluster randomized controlled Comorbid Affective Disorders, AIDS/HIV, and Long Term Health (COBALT) trial are examining the methods for and impact of integrated mental health and HIV services in a subset of health facilities in two districts in North West Province, South Africa. Simultaneously, a CDC-funded collaboration of the University of Washington, I- TECH South Africa, and the University of KwaZulu-Natal is strengthening these efforts and scaling to two new districts. By leveraging these projects, and triangulating robust quantitative and qualitative data, this study will address key gaps in knowledge about the factors associated with the successful integration of mental health and HIV services. This will be the first study to apply a rigorous framework for implementation science research, including validated measures of predictors of successful implementation, to the investigation of the process of integrating mental health and HIV services in a low-resource setting. Moreover, assessment of these barriers and facilitators will lead directly to refinement of approaches to scale-up in South Africa, improving scale-up and subsequent patient outcomes.