Webinar Notes

MENTAL HEALTH SERIES #3
THE TIME IS NOW: ADDRESSING MENTAL HEALTH NEEDS OF PEOPLE LIVING WITH, AT RISK OF, OR AFFECTED BY HIV AND TB

On 11 December 2024, Global Fund Advocates Network Asia-Pacific (GFAN AP), United for Global Mental Health (UnitedGMH), and the Seven Alliance jointly hosted the third and final webinar of the three-part series titled “The Time is Now: Addressing Mental Health Needs of People living with, at risk of, and/or affected by HIV/TB”.

The final installation of the three-part series aimed to facilitate the sharing of best practices on strategies and opportunities via global, bilateral, and domestic financing for integrated HIV, TB, and mental health services; increase awareness among donors about the urgency of integrating and investing in mental health services in HIV and TB programmes; and foster collaborations between donors, technical agencies, community and civil society to create synergies for integration of mental health components into the existing HIV and TB funding mechanisms.

The webinar was attended by over 45 participants from Asia-Pacific, Africa, North America and Europe and was co-moderated by Jennifer Ho (Operations Manager, GFAN AP) and Yves Miel Zuniga (Policy & Advocacy Advisor, UnitedGMH). Six key speakers were invited from partner organisations to share about their experiences with resource mobilisation from domestic and global funding opportunities in the contexts of their health programmes: Prabha Mahesh, Director of Health Projects at ALERT INDIA; Roy Dahildahil, Co-Founder of MentalHealthPH; Stephen Mills, Asia Regional Director, USAID EpiC Project at FHI 360; Vương Anh Thu, Associate Director, Health System Strengthening at EpiC Vietnam; Trần Thị Thanh Quý, Project Specialist at EpiC Vietnam; and Dr. Prasana Khatiwoda, Technical Specialist at EpiC Nepal.

The webinar commenced with welcome remarks by Jennifer Ho, Yves Miel Zuniga, and Bikas Gurung (Regional Coordinator, NAPUD) representing the Seven Alliance. The floor was then passed to the invited speakers for their respective presentations.

Presentation #1: “TB & Mental Health” by Prabha Mahesh, ALERT INDIA

The first presentation by Prabha Mahesh provided an overview of ALERT INDIA’s work on tuberculosis (TB) and mental health in India, which highlighted the bidirectional relationship and impact of both conditions on one another. Every year, approximately 2.6 million new TB cases are reported and around 400,000 people die from TB in India, making India the country with the highest TB burden globally. TB can significantly impact mental health, leading to conditions like depression, anxiety, and suicidal ideation. Conversely, mental health conditions can increase the risk of contracting TB and hinder its treatment. The effects of TB and mental health also differed by gender, affecting men and women patients differently.

Some of the challenges encountered in India’s context are a lack of awareness, entrenched stigma in families and communities, inadequate mental health infrastructure and funding resulting in poor quality of care, a lack of coordination between TB and mental health services, poverty and economic barriers to treatment, the emergence of drug-resistant TB, the adverse effects of TB treatment on mental health, and the need for greater advocacy and community mobilisation to break barriers. Some strategies to address the dual burden of TB and mental health include early identification and screening, provision of psychosocial support, medication management, stigma reduction efforts, a multidisciplinary approach to care, capacity building of health care workers, and the integration of mental health care in the TB care cascade.

Some sources of funding for mental health and TB programmes in India are the National Mental Health Programme (NMHP), which provides financial support for rehabilitation, skill enhancement, and community living for people recovering from mental illness, and the National TB Elimination Programme, which provides free TB diagnosis, treatment, and adherence through patient incentive programmes. However, there is a gap in funding at the intersection of TB and mental health, as there is no fund that addresses TB and mental health programming in combination.

Presentation #2: “Philippine Mental Health and Universal Health Care Law” by Roy Dahildahil, MentalHealthPH

The next presentation by Roy Dahildahil provided an overview of mental health care in the Philippines following the passing of the Mental Health Act in 2018 and Universal Health Care Act in 2019. Roy presented a case study of an adult Filipino mental health service user who was diagnosed with bipolar II disorder and generalised anxiety disorder, whose out of pocket expenditure for mental health treatment would total US$180, in a country where average monthly income is approximately US$230. Due to high costs of treatment, a lack of physical manifestations, and stigma, mental health conditions are often kept hidden than addressed through professional care.

During Mental Health Day in October 2023, the Philippines’ National Government Insurance programme (PhilHealth) expanded its coverage to include general and specialized mental health services, which entitled every Filipino to receive US$150-280 in insurance coverage to cover essential diagnostic services, assessment and follow-up consultations from accredited facilities on top of free medications for mental health. The insurance covers mental health conditions related to depression, psychosis, epilepsy, child adolescence, mental health and behavioral disorders, dementia and self-harm related problems.

However, progress on this front has been slow, low, and siloed. Despite the passing of the Mental Health and Universal Health Care Acts in 2018 and 2019 respectively, the PhilHealth outpatient package for mental health services was only launched 5 years later. Even now, fewer than 10 facilities all over the Philippines have been accredited to offer free services, which is insufficient to cater to the country’s needs. Additionally, the allocation of US$150 per year to cover professional fees is not enough to cover the majority of the expenses needed for quality, mental health care.

There is also a lack of personnel to run newly built mental health facilities, such as trained doctors, mental health professionals, and health care workers who are sensitised to patients living with HIV and TB. Other challenges are the affordability of medicine and the need to focus on promotive and preventive aspects of health. Lastly, mental health services need to be integrated with the larger healthcare system as mental health conditions are closely interrelated with other health conditions such as HIV, tuberculosis, infections in cancer, and others. Mental health interventions must not be compartmentalised but comprehensive.

Presentation #3: “Mental health and psychosocial support integration in EpiC programming” by Stephen Mills, FHI 360; Vương Anh Thu & Trần Thị Thanh Quý, EpiC Vietnam; and Dr. Prasana Khatiwoda, EpiC Nepal

The third presentation began with an introduction by Stephen Mills about the EpiC Project, a global HIV project supported by USAID currently in its fifth year of operation in Asia. Operating in 13 different countries, EpiC Project aims to support the introduction and scale up of HIV cascade interventions through HIV testing, prevention including the use of PrEP (pre-exposure prophylaxis), and antiretroviral treatment among key populations. During the advent of COVID-19, advocacy from community partners to USAID to incorporate more mental health interventions into programming was very actively received and over the past 3 to 4 years, EpiC Project has seen active growth of mental health related services for key populations, including men who have sex with men, transgender populations, people who inject drugs, and sex workers.

Vương Anh Thu & Trần Thị Thanh Quý presented on EpiC Project’s work in Vietnam. Thu highlighted that integrating mental health services into HIV programming is essential for achieving comprehensive care, which improves mental health and HIV outcomes as well as enhancing clients’ quality of life. EpiC Vietnam’s integration of mental health services into HIV programmes is guided by the 8Cs model, which ensures a systematic and client-centred approach while also supporting health care providers. When EpiC Vietnam integrated mental health into HIV services starting in 2022, results of the baseline assessment showed that 80% of HIV services providers needed training on mental health, while 45% of clients reported needs for mental health counseling. Based on this finding, EpiC Vietnam trained health staff at HIV treatment services on basic knowledge and mental health screening with a focus on key populations using standardised tools, where they found from data analysis that the mental health identification rate was lower than estimates for the general population in Vietnam, except at one clinic which applied self-administered screening, compared to a counselor-led approach applied by other clinics. This prompted a south-to-south learning exchange to introduce self administered screening to other sites.

One of the major gaps had been the referral between HIV and professional mental health services, which has prompted closer collaborations with public HIV treatment facilities, PrEP clinics, and mental health facilities to improve referral networks. Additionally, EpiC Vietnam has expanded engagement with the broader LGBTQI+ community through collaborations with a local social enterprise and is developing an online booking platform to increase the accessibility of clients to mental health services. EpiC Vietnam is also working with the Ministry of Health to standardise a national mental health training curriculum for health staff, first developed in 2022, which will be used to expand training broadly in Vietnam through local national training programmes.

Quý shared about the mental health programme implemented in Ho Chi Minh City, which aims to strengthen communication and raise awareness among healthcare workers, build capacity for mental service delivery to wellness navigators, and to improve leadership, understanding and positive work control through activities such as leadership trainings. Ultimately, the programme aims to build capacity for mental health services delivery by training wellness navigators to lead communities of practice. Wellness navigators are existing hospital staff whose role is to enhance mental health services delivery by supporting providers in screening and access to services, cultivating a supportive network, collaborating with other navigators, and monitoring activity. In Ho Chi Minh City, EpiC Vietnam has trained 160 healthcare workers from 67 health facilities among the province to serve as focal wellness navigators. EpiC Vietnam has also mapped out psychological and psychiatric services as well as primary care clinics on an integrated database hosted on Google Maps.

Dr. Prasana presented on EpiC Nepal’s experience with integrating mental health services into HIV programming, which began in 2022 and covered 37 districts of the country. Some key interventions that supported the integration of mental health services were carrying out mental health screenings at community and clinic-based HIV testing sites, developing SOPs to guide screening and referrals, training non-mental health professionals to conduct screening and basic care, and building a mental health service referral system with trained medical professionals. EpiC Nepal uses three mental health screening tools in their referral system: Kessler 6 to screen for initial psychosocial distress, PHQ-9 for depression, and AUDIT-C for harmful alcohol use.

An initial challenge with the mental health screening integration was low coverage and very low rates of detection. The team noticed that Kessler 6 was diagnosing psychosocial distress more at clinics than at community screening sites, which prompted the introduction of the community informant detection tool (CIDT) and provision of community-based education by community workers. Other challenges faced were language and cultural barriers as well as the limited number of mental health experts which affected referrals and linkages.

To overcome these challenges, the team has provided more training to laypersons, community workers, and case managers; increased human resources for mental health; strengthened their referral networks; and coordinated with the government to develop a national standard operating procedure (SOP) on mental health services for key populations, while conducting continuous assessments of the mental health integration system. Dr. Prasana concluded with EpiC Nepal’s targets for 2025: to strengthen engagement with beneficiaries; improve coordination with the government; strengthen referral networks; and use online booking applications to increase further coverage for mental health and HIV services.

Stephen closed out the presentation by EpiC Project, reaffirming the intensive use of data as feedback to make adjustments on the workforce and the quality of training, to ensure better service quality in the future.

Q&A session

Yves moderated the Q&A session and started off with a question: How do organisations such as ALERT INDIA and MentalHealthPH foresee potential collaborations in the future, and are what are the most immediate action points for civil society and community organisations to accelerate the integration of mental health, TB, and HIV?

Prabha shared that a key challenge is a shortage of funds. In response, ALERT INDIA has conducted a mapping of resources, and by engaging with experts and interns from larger mental health institutions, they were able to secure training for personnel on small honorarium amounts. This has been a win-win for her organisation as well as the mental health institutions involved.

Roy shared that mental health, TB, and HIV are still highly stigmatised issues, so advocates working on these topics could share best practices on how to destigmatise these public health issues and how to improve and educate more in the mental health space. For example, in the Philippines there is a lack of trained psychiatrists who are trained on HIV topics and advocacy. More investment is needed to ensure persons with live experiences are able to receive mental health care and services that are appropriate for them.

Stephen shared that a challenge for many organisations, who often depend on international donors, is the difficulty in securing domestic funding from host governments. Thailand is an example where the National Health Security Office (NHSO) has started to fund community-based organisations for their HIV testing and some PrEP support. The NHSO has started to acknowledge the value of mental health services provided by these organizations, which could soon result in some mental health reimbursements to these community-based organizations by the Thai government. This could be an avenue for advocacy for other HIV organisations in the future as well.

A question for FYI 360 and EpiC Project asked, what are the potential challenges that they observed when scaling up their interventions to a larger level of coverage, besides cultural barriers and a lack of mental health workforce?

Dr. Prasana shared that a key challenge is funding and for mental health to be given the same importance as physical health. In South Asia, mental health is often invisible and unseen, so it is important for sustainability that more people understand that mental health is actually a really big problem.

Harry Prabowo (Program Manager, APN+) asked, given the challenge of stigma around mental health which is prevalent in Southeast Asia, how does EpiC Project conduct effective mental health screenings with communities?

Dr. Prasana shared that the 1st level of screening, i.e. the Kessler 6, is carried out both in communities by community workers providing HIV services, as well as at clinics when individuals seek out HIV services. The data we collected had indicated that community-level mental health screening was detecting very low levels of psychosocial distress compared to clinic-level screening, despite the high coverage. This implied that people are probably more willing to talk about mental health challenges in a clinic setting, rather than in community settings.

Jennifer wrapped up the Q&A session with a group photo.

Sharing of GFAN AP’s Global Fund Eighth Replenishment campaign

Jennifer shared that one of GFAN AP’s objectives is to facilitate consolidated advocacy efforts by communities and civil society in our region towards sufficient investments in health, in particular financing for HIV, TB, and malaria through increased global and domestic resource mobilisation. The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is an important funding mechanism for the Asia-Pacific region, and GFAN AP continues to advocate to the Global Fund and the many government and private donors who contribute to sustain the programs and services that we need, including mental health services.

Ken Khoo (Communications Officer, GFAN AP) was then invited to share the brief overview of the Asia-Pacific developed communities and civil society campaign for the Eighth Replenishment of the Global Fund. This campaign is a collective output of multiple consultations with Asia-Pacific communities and civil society organisations, and the development and finalisation of the campaign was supported by a communications working group with members from the Asia-Pacific region.

The tagline and hashtag for the campaign — #MoreNowThanEver — was agreed upon by the communications working group members to highlight the urgency and importance of this replenishment cycle in the fight against the three diseases, particularly in light of our 2030 goals.

Campaign messaging will anchor on four core thematic areas:

  • #LetCommunitiesLead, which calls for more equal voices at the table and a shifting of power, and for communities to be at the forefront of conversations and decisions at all levels;
  • #ConnectTheGaps, which addresses not only funding gaps, but also gaps in access and engagement, ensuring that all key and vulnerable populations are included in our advocacy;
  • #AccountabilityForAll, which emphasises that all stakeholders have a role to play in ensuring equitable access to health through differentiated approaches and strategies in the way we carry out programmes in different country contexts; and
  • #OurRightsOurLives, a call for governments to protect our rights as citizens and communities while respecting our civil liberties, also intended to address the concern issue of shrinking civic spaces.

The campaign will be visually represented by stars, whilst the community activity and mobilisation efforts will be through folded paper stars, a traditional handicraft which carries symbolisms of good fortune, support, and love. Folded from a single strip of paper, paper stars are a cheap and accessible craft which can contain messages within. In its presentation to donors and stakeholders, these messages represent the voices we wish to bring to the table from community members who may not have the opportunity to be there in person.

Ken concluded by sharing that GFAN AP is currently finalising the Eighth Replenishment campaign calendar and will be sharing more on the upcoming activities and timelines anticipated with the campaign soft launch coming up soon.

Jennifer highlighted that integrated mental health services was also a topic discussed during community consultations that is being incorporated in the Eighth Replenishment campaign as a key area of work that needs to be resourced and funded by the Global Fund.

The webinar ended with closing remarks by Yves and appreciation to presenters, participants, and co-organisers for their continued support in advocating for mental health integration and best wishes for the new year period.

SPEAKERS:

Prabha Mahesh

Prabha Mahesh

Director of Health Projects, ALERT India. India.

Prabha Mahesh is a public health professional with a deep commitment to ending tuberculosis (TB). She holds qualifications in psychology, social work, psychoanalysis, and healthcare management. Currently, she is the Director of Health Projects at ALERT India, where she designs and implements innovative programmes to address TB, HIV and Community Health.

Prabha has designed pilots for DSTB & DRTB, developed interventions to optimize service delivery, community mobilization, and developed tools for ACSM to ward off stigma. She has conceptualised and implemented various programmes with multi-stakeholders to address TB from different perspectives; conducted gap analysis in service delivery and explored possibilities from CSR support to address these to build effective delivery models; is a pioneer in embracing technology in healthcare partnered with PATH, interfacing with Private Providers in TB control, funded by the Gates Foundation; and implemented 21 pilots that have transitioned to national programmes, e.g. PPSA, ABDM, Chest X-ray model, Public Health action, DRTB, HIV, Cartridge sharing model, Nutrition, with the latest being ABDM.

Vương Anh Thu

Vương Anh Thu

Associate Director, Health System Strengthening, EpiC Vietnam. Vietnam.

Ms. Vương Anh Thu serves as EpiC’s lead for Health System Strengthening within the HIV portfolio. In her role, she oversees the HIV Treatment Program, providing technical assistance to address systematic challenges while ensuring quality service delivery. Additionally, Ms. Thu leads the mental health initiatives within the HIV program and has been instrumental in driving the implementation of Pre-Exposure Prophylaxis (PrEP), contributing to enhanced prevention and treatment services in Vietnam. She also has helped lead other innovations in advanced HIV disease, non-communicable diseases management, and transition towards sustainability.

Ms. Thu holds a Public Health degree from Hanoi Medical University (2006) and a Master of Health Management from The University of New South Wales, Sydney, Australia (2011). Ms. Thu has worked for FHI 360 since 2011, and accumulated nearly 20 years of experience supporting people living with HIV and other vulnerable populations to access world-class care.

Roy Dahildahil

Roy Dahildahil

Co-founder & Executive Director, MentalHealthPH. The Philippines.

Roy Dahildahil is a co-founder of MentalHealthPH, an organization in the Philippines dedicated to promoting mental health awareness and providing resources and support for mental well-being. MentalHealthPH aims to create a safe space for people to discuss mental health issues, break the stigma associated with mental health conditions, and connect individuals with the help they need.

Through his work with MentalHealthPH, Roy Dahildahil has been actively involved in various initiatives, including online campaigns, educational programs, and community outreach, all aimed at improving mental health literacy in the country. The organization uses social media and other platforms to share information, offer support, and advocate for better mental health policies and services in the Philippines. Roy was also listed as one of the 2022 Leading Lights (Kindness in Leadership) Listee for Asia and Pacific. He is a proud queer, lgbtqia+ and HIV and AIDS advocate.

Trần Thị Thanh Quý

Trần Thị Thanh Quý

Project Specialist, EpiC Vietnam. Vietnam.

Ms. Trần Thị Thanh Qúy has been with the EpiC project’s COVID initiative since August 2021. In her role, she leads efforts in oxygen support, medical equipment, and supplies delivery, as well as contract management and project implementation. She works closely with the Ministry of Health and key partners to enhance LOX infrastructure and strengthen oxygen delivery systems. In addition to her work in oxygen support, Ms. Qúy has focused on building capacity for mental health service delivery and has implemented interventions for healthcare workers in Ho Chi Minh City.

With a background in international business, she brings over 10 years of experience in procurement, forecasting, and supply chain management for USAID PEPFAR public health commodities, including ARVs and methadone, driving initiatives towards self-reliance in country self-procurement.

Stephen Mills

Stephen Mills

Asia Regional Director, USAID EpiC Project at FHI 360. Thailand.

Stephen Mills, PhD, MPH is Asia Regional Director for the USAID EpiC Project at FHI 360. In this capacity, he manages interventions and approaches that try to optimize the HIV prevention, care, and treatment cascade for key populations, especially community-based approaches that reduce stigma and discrimination. He also is involved in the sustainability of these approaches through promoting social contracting and universal health care (UHC) reimbursements from governments to community-based organizations and through the formation of social enterprises that generate program income for these organizations. Steve is a Commissioner in the newly formed Lancet Commission on People-Centered Care for Universal Health Coverage and has served on the Technical Review Panel for the Global Fund on HIV and Equity, Human Rights, and Gender.

Dr. Prasana Khatiwoda

Dr. Prasana Khatiwoda

Technical Specialist, EpiC Nepal. Nepal.

Dr. Prasana Khatiwoda is a Technical Specialist for Epic Nepal at FHI 360 Nepal office. She is a clinician with global/public health background, and for the past two years has been actively involved in advancing mental health integration into HIV care programs across Nepal.

PRESENTATIONS: