Integration of stepped care for Perinatal Mood and Anxiety Disorders among Women Living with HIV in Kenya

项目总结/摘要 围产期情绪和焦虑障碍（PMAD），定义为妊娠期间或1年内的抑郁和焦虑 产后一年，影响10-20%的孕妇和产后妇女， 低收入国家（低收入国家，>20%）和感染艾滋病毒的妇女（WLWH，>25%）。满足PMAD需求 低收入国家中WLWH的治疗需要将循证干预（EBI）纳入常规治疗中， 产前和预防母婴传播艾滋病毒服务。 在肯尼亚，这些努力已被列为国家精神卫生政策战略的优先事项，但其实施一直受到限制。 由于缺乏提供者培训和提供者干部之间联系不佳而受到限制（例如，初级保健和心理健康 供应商）。有必要制定和测试有针对性的干预措施，以加强劳动力队伍 能力和促进提供者干部之间的联系，以及促进高 提供高质量的干预。 我们已经确定了三种EBI来促进围产期心理健康：（1）普遍的心理健康筛查，（2） 问题管理加（PM+）咨询干预的妇女经历PMAD，和（3）远程精神病学 对于症状严重或对PM+无反应的女性。我们建议将这些干预措施联合收割机结合起来， 阶梯式护理模式，名为综合围产期心理健康计划（IPMH），并制定 在肯尼亚，我们正在实施战略，支持将艾滋病毒/艾滋病纳入预防母婴传播的常规护理。然后我们将 在一项混合II型随机分组试验中评估IPMH的有效性和实施结果 在肯尼亚西部的20个医疗机构，该地区是该国艾滋病毒流行率最高的地区。 在目标1中，我们将使用参与式设计来优化和调整IPMH并制定实施策略。 在目标2中，我们将确定IPMH及其实施策略对心理健康、艾滋病毒护理和 WLWH从怀孕到产后6个月的妊娠结局。在目标3中，我们将确定效果 的政策和实施策略，并确定 成功实施的多层次驱动因素。 我们假设IPMH在常规预防母婴传播服务中提供阶梯式护理干预，沿着 量身定制的实施策略，将（1）导致更低的抑郁和焦虑症状，降低不良反应， 怀孕结果和更好的生活质量;（2）提高保健服务的普及率和公平性， WLWH经历PMAD。 IPMH有可能解决资源有限环境中WLWH中PMAD治疗的关键差距。 这些目标的完成将产生关于IPMH的有效性和 实施战略，以高质量和可持续地提供随时可扩大规模的干预措施。

PROJECT SUMMARY/ABSTRACT Perinatal mood and anxiety disorders (PMAD), defined as depression and anxiety during pregnancy or up to 1 year postpartum, affect 10-20% of pregnant and postpartum women, with elevated burden in low- and middle- income countries (LMICs, >20%) and among women living with HIV (WLWH, >25%). Meeting the need for PMAD treatment among WLWH in LMICs requires integration of evidence-based interventions (EBIs) into routine antenatal and prevention of mother to child HIV transmission (PMTCT) services. In Kenya, such efforts have been prioritized in national mental health policy strategy, but their delivery has been limited by lack of provider training and poor linkage across provider cadres (e.g., primary care and mental health providers). There is a need for development and testing of tailored interventions that strengthen workforce capacity and facilitate linkage across provider cadres, as well as implementation strategies to facilitate high- quality intervention delivery. We have identified three EBIs to promote perinatal mental health: (1) universal mental health screening, (2) the Problem Management Plus (PM+) counseling intervention for women experiencing PMAD, and (3) telepsychiatry for women with severe symptoms or no response to PM+. We propose to combine these interventions in a stepped care model, named the Integrated Perinatal Mental Health program (IPMH), and develop implementation strategies to support its integration into routine PMTCT care in Kenya. We will then evaluate IPMH’s effectiveness and implementation outcomes in a Hybrid Type II cluster-randomized trial in 20 healthcare facilities in Western Kenya, the region with the highest HIV prevalence in the country. In Aim 1, we will use participatory design to optimize and adapt IPMH and develop implementation strategies. In Aim 2, we will determine the effect of IPMH and its implementation strategies on mental health, HIV care, and pregnancy outcomes among WLWH from pregnancy to 6 months postpartum. In Aim 3, we will determine effect of IPMH and its implementation strategies on service delivery and implementation outcomes, and identify multilevel drivers of successful implementation. We hypothesize that provision of the IPMH stepped care intervention in routine PMTCT services, along with tailored implementation strategies, will (1) lead to lower depression and anxiety symptoms, lower adverse pregnancy outcomes, and better quality of life; and (2) increase penetration and equity of care provision to WLWH experiencing PMAD. IPMH has potential to address a critical gap in treatment of PMAD among WLWH in resource-limited settings. Completion of these aims will generate rigorous data on both IPMH’s effectiveness and the implementation strategies for high quality and sustainable delivery of a ready-to-scale intervention.