Mental Health Problems Affecting People Who Have HIV and AIDS in Malawi : A Review

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.


Introduction
Malawi is located in the southern part of Africa.The country has an estimated population of more than 16 mil-lion 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].

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.

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.

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-

Exploratory study
Respondents 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.

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].

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.

Table 1 .
Summary of studies that were conducted in Malawi on mental health and HIV/AIDS.