Depression And HIV/TB In Southern Africa: A Mixed Method Evaluation of An Integrated Primary Care Mental Health Programme In Eswatini

Abstract Background: Depression and comorbidity with chronic illnesses is common in Southern Africa, yet there are major treatment gaps. This study evaluates the intervention ‘Healthy Activity Program’ to bridge this gap, which involves training non-specialist nurses in depression: including identification, counselling based on behavioural activation theory and structured referral. This intervention aims to be integrated into routine primary healthcare services for HIV/TB. The patient cohort were people living with HIV and/or tuberculosis (TB) (PLHIV/TB) in rural Eswatini. Aims: To assess the feasibility and acceptability of this intervention and concepts of depression in this setting.Methods: This is a pragmatic mixed methods evaluation of a pilot integrated service. Results: 324 PLHIV/TB were screened for depression, with 19% (62/324) screening positive. Attendance to counselling declined over time, with 16/62 attending the minimum 5 sessions. Qualitative results indicated acceptability, yet concerns around feasibility. Conclusions: The ‘Healthy Activity Program’ represents a promising option to manage the treatment gap for depression in PLHIV/TB. However, task-shifting onto non-specialist healthcare professionals with the aim to integrate care for these conditions in primary care, without increasing staff capacity, is a barrier to implementation. Realistic and pragmatic assessments of capacity and workforce are essential.