Integration of mental health and HIV service delivery in low- and middle-income countries: A systematic review of effectiveness.

Abstract

Human immunodeficiency virus (HIV) and mental health have complex, bidirectional impacts. Integrated service delivery, especially in low- and middle-income countries (LMICs) where resources are most limited and the burden of HIV is heaviest, may help to improve both HIV and mental health outcomes. While the integration of mental health and HIV services has been studied in various settings, previous reviews on this topic have primarily focused on the integration processes rather than health outcomes. In this systematic review, we evaluated the effectiveness of interventions in LMICs that integrated mental health and HIV services. We searched PubMed, CINAHL, Sociological Abstracts, PsycINFO and EMBASE and conducted backward and forward citation searches. We included studies conducted in LMICs that evaluated the integration of services for HIV and mental health conditions using pre-post or multi-arm study designs, published in a peer-reviewed journal from January 2000 through January 2024. Studies on substance use services were excluded. Risk of bias for included studies was assessed using the Evidence Project tool. We summarized findings narratively, including both mental health-related and HIV-related outcomes. Eighteen studies with a total of 9,729 participants were included in the analysis, among which 17 studies were conducted in sub-Saharan Africa and 10 were randomized controlled trials. Seventeen studies used a task-sharing approach, where nonspecialists provided mental health interventions. The low follow-up rate and lack of random participant selection suggested the increased risk of bias in most studies. Overall, interventions that integrated mental health and HIV services provided greater improvement in recipients' mental health symptoms (e.g., depression and post-traumatic stress disorder) than HIV services alone, often reducing symptom scores by more than 50%. While the evidence on HIV-related outcomes (e.g., antiretroviral therapy adherence, viral suppression and HIV stigma) was more limited, most studies that reported these outcomes showed positive effects of integrated interventions, especially community-based ones. These findings suggest the benefit of the interventions that integrate mental health and HIV services in LMICs, although further evaluations are warranted.