Improving access to mental health services
PATH is making mental health care more accessible for people at risk for or living with HIV in Vietnam.
Primary health care
Health systems strengthening
Integrated health services
(pictured above) A counselor at Glink clinic in Ho Chi Minh City screens a client for symptoms of depression, anxiety, and stress. Photo: Glink Vietnam.
The challenge
Mental health conditions are common among people living with HIV and key populations at risk for HIV, including men who have sex with men, transgender people, drug users, and sex workers. In fact, programmatic monitoring data from Vietnam suggests that people living with HIV may have up to six times greater risk of mental health illness compared to the general population.
Elevated levels of anxiety, stress, depression, or other mental health conditions can reduce the overall quality of life and can affect health care–seeking, including adherence to and continuation of antiretroviral therapy (ART), pre-exposure prophylaxis (PrEP), and postexposure prophylaxis (PEP)—three critical interventions for treating and preventing HIV.
While an increasing body of evidence shows the integration of services for HIV, mental health, and psychosocial support across the life course is essential for improving HIV outcomes and overall well-being, mental health screening, treatment, and care are often not integrated into packages of essential services and care in low- and middle-income countries. In Vietnam, mental health services tend to be expensive and are rarely offered alongside HIV prevention and treatment.
USAID/PATH STEPS project monitoring data from five one-stop shop private clinics, Dec 2021 – Sept 2022; Vuong DA et al Mental health in Vietnam: burden of disease and availability of services. Asian J Psychiatr. 2011;4(1):65–70.
The solution
The USAID/PATH Healthy Markets project sought to make mental health care more accessible for people at risk for or living with HIV. In 2017, the project began to incrementally add on sexually transmitted infection testing and other screening services to core HIV care provided at key population–led private clinics.
It then partnered with five private clinics in Hanoi and Ho Chi Minh City in 2019 to launch a more comprehensive one–stop shop (OSS) integrated care model offering a range of high-quality PHC services alongside essential HIV services.
Through this model, mental health assessment, counseling, and referrals are integrated within ART, PrEP, PEP, and other routine health services at the clinics.
Why was PATH chosen to do this work?
PATH has been working in Vietnam for 41 years, alongside leaders, communities, partners, and local change makers.
PATH has a strong track record in developing, deploying, and scaling integrated care models to increase health care access, uptake, and retention; maximize health system efficiencies; and better respond to what people need and want. We foster learning on how best to integrate and bundle services by population and context.
USAID /Vietnam awarded PATH the eight-year (2014 to 2021) Healthy Markets project, funded through US President’s Emergency Plan for AIDS Relief (PEPFAR), as well as the five-year (2021 to 2026) Support for Technical Excellence and Private Sector Sustainability in Vietnam (STEPS) project, to implement a fit-for-purpose HIV response in Vietnam.
Over the years, through several studies and through feedback provided at clinics, key populations in Vietnam have indicated a range of health care needs that may include, but are not exclusive to, HIV prevention and treatment. We leveraged these insights and PATH expertise to deploy the OSS model that offers a wider range of integrated, person-centered PHC services.
Our approach
Clients at five key population–led and key population–friendly PHC clinics in Hanoi and Ho Chi Minh City are invited to self-screen for mental health conditions in the waiting room or counseling area using tablets or their smartphones, or they may opt to receive assistance from health staff to fill out the form. The online screening form includes DASS-21, AUDIT-C, ASSIST, and a suicide risk questionnaire—clinical screening tools for providers to assess clients for symptoms of depression, anxiety, stress, alcohol and substance use disorders, and suicide risk.
Clients are then triaged based on their screening results and offered counseling for any mental health conditions identified. Clients who exhibit mild or moderate symptoms are counseled in-clinic and receive psychoeducation support.
Clients with more severe mental health symptoms are counseled and referred to expert psychiatric care, while continuing to receive supportive counseling and other services at the clinics.
During follow-up visits—including appointments for ART, PrEP, and PEP—clients are offered mental health rescreening and assistance in developing personal action plans for managing their mental health conditions.
Mental health pathway of care at key population–led private OSS clinics.
To support the implementation of the model, the project equipped clinic teams with service delivery and quality improvement tools, and delivered tailored training and technical assistance to build providers’ skills and knowledge in mental health service delivery. The project also implemented mental health–focused online and offline communications to boost mental health awareness and health care–seeking.
The results
From October 2020 to October 2022, 7,853 clients received mental health screening, of whom 14 percent presented with a mental health condition, and more than 75 percent of those received counseling and treatment.
The most common condition identified was anxiety (10.2 percent), followed by stress (6.5 percent), and depression (3.0 percent). Nearly two-thirds of clients reached were aged 15 to 29 years old, indicating the importance of this model for supporting youth, a population who is at particularly high risk for mental health disorders.
Importantly, this client-responsive service delivery model, rooted in PHC, led to a substantial increase in mental health service use. At the five clinics, the uptake of mental health services increased by 31 percent following the implementation of the OSS model.
We found mental health morbidity to be high among ART, PrEP, and PEP users, and significant association between mental health morbidity and reduced continuation of PrEP. PrEP clients with mental health conditions were 50 percent more likely to drop out of PrEP before three months compared to those without mental health conditions (OR = 1.5, p < 0.001, 95 percent CI 1.2–1.8).
This suggests that expanding the integration of mental health care with these services remains an essential strategy for strengthening quality of care and addressing underlying barriers to HIV treatment uptake and adherence.
In the upcoming period, the STEPS project will enhance support to OSS clinics to boost mental health screening, linkage to care, and client monitoring. Concurrently, STEPS is working with the Ministry of Health and other partners to replicate the OSS model in additional public- and private-sector sites across the country, toward advancing a new frontier of community-led, sustainable PHC.
Funding
PEPFAR through USAID Vietnam.