P3A044: Barriers to Engagement in Depression and HIV Treatment Among Adolescents in Malawi, a Patient Perspective

Background: Depression is a significant barrier to HIV treatment amongst adolescents living with HIV (ALWH). In Malawi, there is an estimated 75,000 ALWH and 1 in 4 ALWH experience depression. HIV treatment adherence and viral suppression is much lower in adolescents than in adults. This preliminary analysis aimed to explore barriers to engaging in HIV and mental health care from ALWH’s point of view. Results are intended to inform the future adaptation of psychosocial counseling and peer support intervention for HIV engagement.

Methods: This qualitative study included ALWH with comorbid depression between the ages of 13-19 years receiving HIV care from two public antiretroviral therapy (ART) clinics in Lilongwe, Malawi. We conducted nine semi-structured, in-depth individual interviews. Transcripts were read in full to determine general themes that were used to produce a codebook. The data were coded by multiple reviewers using Dedoose. We then thoroughly examined themes related to barriers to HIV and mental health treatment to synthesize the patients’ perspectives.

Results: Many ALWH described feeling discriminated against and stigmatized within their community and peer groups due to their HIV status and mental health struggles. The social stigma and discrimination surrounding both of these conditions was a barrier to engaging in their respective treatments. The cost of transport and distance to the clinics was also identified as a common barrier. Many adolescents mentioned privacy was very important to them due to the fear that people would mock them for needing either treatment or would gossip about it to others. However, it was more frequently specifically mentioned that there was a fear of being seen accessing mental health care. Food insecurity was not only found to cause depression, but many felt unable to take their antiretrovirals (ARVs) on an empty stomach. The youth’s HIV status was also a factor in their depression, which in turn resulted in decreased adherence to ARVs and difficulty attending appointments at the ART clinic.

Conclusion: Resource-appropriate and youth-friendly interventions that address engagement in HIV and mental health care for ALWH are crucially needed and should focus on improving privacy and accessibility. Community efforts to reduce the stigma of HIV and depression may also improve engagement in care. Improving food security and mental health accessibility may address depressive symptoms and remove additional barriers to HIV treatment.