Abstract Body

Mental and substance use disorders are highly prevalent and rank among the leading causes of disability worldwide, accounting for nearly 20% of the global burden of disability in 2015. Among these, depressive disorders contribute the greatest burden and are the most prevalent, with an estimated 311 million cases globally in 2015. These are disabling disorders of youth, responsible for a greater percentage of disease burden among 15-49 year olds, thus affecting educational, employment, and relationship functioning. Notably, mental disorders frequently co-occur with HIV, both as risk factors and sequelae of HIV infection. Major depression occurs nearly twice as often among people with HIV infection and is associated with poor adherence to care, lower likelihood of virologic suppression, greater morbidity and mortality. Depression is associated with greater mortality in the initial years after antiretroviral initiation. Whereas access to outpatient mental health services for people with HIV care occurs frequently in wealthy countries, several barriers have impeded mental health care access in low-and middle-income countries (LMICs) with high HIV prevalence. The dearth of mental health human resources and limited investment in mental health in LMICs reduce access to care. As a result, most health professionals do not identify or treat disorders like depression in community care settings. The social stigma associated with psychiatric institutional care creates an additional barrier to seeking mental health care. The treatment landscape for HIV and depression has changed in recent years. Investments in HIV care and treatment have led to a chronic care infrastructure in some LMICs that can be leveraged to manage other potentially chronic, remitting conditions like depression. A growing evidence base for the use of task-shifting to deliver mental health services in LMICs is expanding options for non-specialists to treat depression. Recent trials demonstrate that lay health workers, nurses, and peers can be trained to effectively deliver evidence-based depression care in HIV and non-HIV treatment contexts. In addition, several validation studies show that commonly used assessments for depression can be meaningfully applied in varied contexts among HIV-positive patients. These developments, along with new goals for epidemic control, make the integration of HIV and depression care in LMICs necessary and feasible.