TY - JOUR T1 - A Mixed-Methods Process Evaluation: Integrating Depression Treatment Into HIV Care in Malawi JF - Global Health: Science and Practice JO - GLOB HEALTH SCI PRACT SP - 611 LP - 625 DO - 10.9745/GHSP-D-20-00607 VL - 9 IS - 3 AU - Melissa A. Stockton AU - Caroline E. Minnick AU - Kazione Kulisewa AU - Steven M. Mphonda AU - Mina C. Hosseinipour AU - Bradley N. Gaynes AU - Joanna Maselko AU - Audrey E. Pettifor AU - Vivian Go AU - Michael Udedi AU - Brian W. Pence Y1 - 2021/09/30 UR - http://www.ghspjournal.org/content/9/3/611.abstract N2 - Key FindingsEarly evaluations of integrating a depression management program using antidepressants and psychotherapy into HIV clinics in Malawi found that depression screening, diagnosis, and treatment initiation were successfully integrated.A follow-up evaluation found that treatment over time was not delivered as intended, clinic staff had mixed attitudes regarding program acceptability, and the program was not sustained.Antidepressants and problem-solving therapy were acceptable evidence-based depression treatments for patients, but clinic staff found delivering these treatments challenging given constrained human resources and infrastructure.Delivery challenges included difficulties identifying and reassessing patients, negative attitudes, lack of integration into the electronic medical records system, medication stock-outs, staff and space availability, cost of transport, generally low retention, and reliance on study staff.Key ImplicationsProgram managers need to invest in program supervision, build and maintain the capacity of providers, integrate into existing electronic medical records systems, and ensure the availability of psychotherapy counselors to more effectively integrate depression treatment into HIV care in these types of settings.Background:Depression is highly prevalent among people living with HIV in Malawi. Depression can undermine engagement in HIV care and worsen HIV morbidity and mortality. The Ministry of Health integrated a pilot depression management program into HIV care at 2 clinics. This program included a measurement-based care protocol for prescribing antidepressants and an adapted Friendship Bench psychotherapy protocol for providing problem solving. Early evaluations indicated successful integration of the initial stages of training and depression screening, diagnosis, and treatment initiation. This follow-up mixed-method investigation contextualizes our previous findings and shares insights from the implementation experience.Methods:We conducted a mixed-methods process evaluation drawing on both patient clinical data and qualitative interviews with patients and clinic staff. We focus on the following implementation outcomes: fidelity, acceptability, and sustainability.Results:Although fidelity to depression screening and treatment initiation was high, fidelity to the follow-up treatment protocol was poor. Antidepressants and problem-solving therapy were acceptable to patients, but clinic staff found delivering treatment challenging given constrained human resources and infrastructure. The program was not sustained after the project. Key identified needs included substantial support to supervise the implementation of the program, continue to build and maintain the capacity of providers, integrate the program into the electronic medical records system, and ensure the availability of Friendship Bench counselors.Conclusions:Although initial steps were successful, sustained integration of this depression treatment program into HIV care in this setting met greater challenges. Implementation science studies that support both implementation and evaluation should recognize the potential for clinical implementers to rely on evaluation staff for clinical support and consider distancing evaluation staff from the actual program implementation. Further research is needed to test enhanced implementation strategies for integrating evidence-based mental health interventions into existing health care systems in a sustainable fashion, particularly in low-resource settings. ER -