Addressing common mental health disorders among incarcerated people living with HIV: Insights from implementation science for service integration and delivery

Abstract

Purpose:

Despite evidence of disproportionate burden of HIV and mental health disorders among incarcerated people, scarce services exist to address common mental health disorders, including major depressive and anxiety disorders, post-traumatic stress disorder, and substance use disorders, among incarcerated people living with HIV (PLHIV) in sub-Saharan Africa (SSA). This paper aims to summarize current knowledge on mental health interventions of relevance to incarcerated PLHIV and apply implementation science theory to highlight strategies and approaches to deliver mental health services for PLHIV in correctional settings in SSA.

Recent findings:

Scarce evidence-based mental health interventions have been rigorously evaluated among incarcerated PLHIV in SSA. Emerging evidence from low- and middle-income countries and correctional settings outside SSA point to a role for cognitive behavioral therapy-based talking and group interventions implemented using task-shifting strategies involving lay health workers and peer educators.

Summary:

Several mental health interventions and implementation strategies hold promise for addressing common mental health disorders among incarcerated PLHIV in SSA. However, to deliver these approaches, there must first be pragmatic efforts to build corrections health system capacity, address human rights abuses that exacerbate HIV and mental health, and re-conceptualize mental health services as integral to quality HIV service delivery and universal access to primary healthcare for all incarcerated people.

Introduction

In sub-Saharan Africa (SSA), effective HIV prevention, treatment, and care for key populations (KP) such as incarcerated people is complicated by mental health disorders (MHDs) (1). These disorders, defined as “behavioral or mental patterns that cause significant distress or impairment of personal functioning,” range from mood disorders like major depressive and anxiety disorders to substance use disorders (SUDs) and serious thought disorders like schizophrenia (2). Because HIV prevalence is higher in incarcerated than general populations, and available estimates suggest that as many as one in nine people involved with the criminal justice system globally suffer from MHDs like depression or anxiety(3), incarcerated people face a substantial dual burden of HIV and MHDs (4). Although less is known about the complex interplay between HIV and MHDs among incarcerated populations, data from general populations indicate that MHDs affect HIV risk behaviors, uptake of HIV testing and prevention services, engagement with the health system, and longitudinal retention in HIV care (5–9).

In this paper, we set out to meet two objectives relevant to implementation science at the intersection of HIV, criminal justice, and mental health. First, we look to describe the current knowledge base on approaches to addressing the HIV and mental health needs of incarcerated PLHIV. We center our discussion on SSA, where the authors have substantial research and programmatic experience. We have purposefully restricted our focus to the most prevalent MHDs encountered in SSA correctional settings—the common mental health disorders (henceforth referred to simply as mental health disorders or “MHDs”)—that encompass major depressive and anxiety disorders, post-traumatic stress disorder (PTSD), and substance use disorders (SUDs). Second, we aim to apply implementation science theory to characterize interventions with some evidence to suggest the possibility of their introduction in under-resourced correctional facilities to improve treatment and care for HIV and MHDs. To this end, we have selected the Practical, Robust Implementation and Sustainability Model (PRISM) for its pragmatic structure, and examination of contextual-, organizational-, patient-, and intervention-level factors(10) applicable to integrating HIV and mental health services in correctional facilities in SSA (Figure 1).

Figure 1. PRISM Framework.

The following references were used in developing this emerging conceptual framework:14–17

We first examine the following relevant implementation science domains and elements adapted from PRISM (Figure 1): Corrections health environment and infrastructure (i.e., External Environment and Implementation & Sustainability Infrastructure); patient and organizational characteristics pertinent to HIV and mental health service delivery (i.e., Recipients); and promising implementation strategies for delivering integrated evidence-based mental health interventions for incarcerated PLHIV (i.e., Intervention). We then conceptualize approaches to introducing evidence-based mental health interventions into existing HIV service delivery platforms applying peer provider-led implementation strategies, and advance an associated policy and research agenda for HIV and mental health care integration in correctional settings in SSA.

Corrections Health Environment and Implementation Infrastructure

Many correctional facilities in SSA are heavily burdened by HIV(11). Although the availability of HIV programs within correctional facilities in SSA varies widely, those that do exist are frequently under-resourced and under-staffed to support robust HIV service delivery. As a result, while HIV testing services (HTS) and referral to antiretroviral therapy (ART) may be available, these services are rarely linked to comprehensive prevention or treatment along the rest of the care continuum, with most incarcerated people lacking access to on-site antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP)(12, 13). Critical patient-level supports for sustained ART or PrEP maintenance are similarly lacking. Nevertheless, promising practices are emerging, particularly for peer navigation during incarceration and after release(14, 15). With the right resourcing, staffing, and policy guidance, more ambitious HIV service delivery approaches, such as universal test and treat are proving increasingly feasible even in the most challenging correctional settings and present promising structures whereby mental health interventions could be integrated (16).

Despite the high burden of mental illness among incarcerated people, particularly those living with HIV, there are few documented examples of systematic efforts to address mental health needs in this population. The reasons for this are myriad and vary between countries and correctional facilities, however, they generally include a lack of recognition on the part of many governments and policy makers of: MHDs generally; their interplay with HIV; the need to provide mental health services to people in correctional facilities; and, consequently, the importance of policy guidance and programs to provide mental health services to incarcerated people, including those living with HIV. This is driven in many countries by deep-seated community norms in which mental illness is highly stigmatized. As a result, in most correctional settings, there are scarce human resources for mental health, limited links to community-based mental health services for justice-involved people before and after incarceration, and deficient pharmacotherapy and psychotherapy-based interventions (17, 18). While corrections health systems are rarely resourced or organized to provide mental health services, there may be opportunities to leverage existing infrastructure from HIV programs to provide a starting point for providing mental health care. Utilizing such infrastructure in an attempt to deliver integrated mental health services to incarcerated PLHIV would require investments to promote feasibility, including: dedicated staffing and funds for mental health services; basic mental health service delivery protocols and procedures for use at field level; training and mentorship for mental health providers; and routine monitoring and data sharing for performance measurement on key mental health indicators.

Introduction and integration of mental health and HIV services requires careful planning, taking into account multiple factors, including mental health knowledge of primary health care staff; existing (typically high) healthcare provider and corrections officer workloads; lack of psychiatric medications, clinical space, and overall infrastructure; and negative attitudes and stigma against incarcerated people with MHDs and even mental health workers(19, 20). However, if planned carefully and executed with consideration for the aforementioned constraints, integrated service delivery could yield a double dividend for HIV and mental health care quality and continuity. Integrating services sustainably also requires broader efforts for criminal justice reform since rights-based deficiencies and structural violence exacerbate emotional and psychological stressors, which in turn accelerate the development of MHDs (Figure 2) (21–24). Undertaking mental health interventions in correctional settings should be done in tandem with pragmatically addressing these factors, which have been widely criticized as inhumane(25).

Figure 2.

Emerging conceptual framework examining the connections among common mental disorders and the corrections health environment, patient characteristics, and implementation infrastructure.

Ensuring care continuity for HIV and MHDs is particularly essential at the time that an incarcerated person is released to the community. Reticence among incarcerated people to engage with correctional services post-release means that corrections staff and systems (e.g. parole boards) may not be well-positioned to facilitate continuity of care. Reliance on sub-optimal mechanisms such as these may increase the risk of recidivism and worsening of mental and HIV health outcomes. Instead, meaningful corrections engagement with civil society organizations, community mental health providers, and HIV treatment programs can support a smoother transition to mainstream HIV and mental health services after release (26).

Finally, MHDs have been shown to play a critical role in HIV acquisition, with evidence of an association between MHDs and risk-taking activities such as condomless sex, multiple sexual partners, and transactional sex(27–29) along with poor uptake of HIV testing and adherence to PrEP(30–32). While some behavioral interventions have been considered to increase the uptake of PrEP(33), there are few descriptions of attempts to implement such interventions within correctional settings, and such interventions should be an area for further study. Mental health interventions within the correctional system should thus not merely focus on persons already living with HIV, but also be tailored to help protect incarcerated persons from HIV both during incarceration and after release.

Incarcerated Population Characteristics and Burden of HIV and Mental Health Disorders

Understanding beneficiary characteristics, service delivery barriers, and disease burden is a PRISM-informed early step in implementation. Based on available evidence and prevalence surveys, incarcerated people in heavily HIV burdened settings in SSA face a high burden of MHDs. Indeed, studies from South Africa, Ethiopia, and Nigeria all document prevalence of depression reaching 55%(34), 45%(35), and 73%(36) in their respective incarcerated populations. This high burden of MHDs extends to incarcerated PLHIV, who may endure higher rates of MHDs than PLHIV in the general community(37). For example, in Ethiopia 66.5% of incarcerated PLHIV were diagnosed with depression(24, 38), and preliminary data from South Africa and Zambia also corroborates this assertion, with the prevalence of major depressive symptoms among incarcerated PLHIV in large correctional facilities in Johannesburg and Lusaka being 46% and 57%, respectively(39). Reasons for this high burden of depression and anxiety are poorly understood, but are likely multifactorial, and may include recurrent victimization, stigma and discrimination, and isolation from family while incarcerated, as well as lack of purposeful and stimulating activities during incarceration(24, 38).

While prospective characterization of SUDs among incarcerated PLHIV in SSA is scarce, insights from the general incarcerated population in SSA suggest a high prevalence of these disorders. In SSA, reported rates of substance use among incarcerated people vary considerably across countries, with poorly described patterns of use before, during, and after incarceration. For example, in South Africa, as many as 45% of incarcerated people in one large correctional facility had evidence of recent methamphetamines and/or cannabis use at the time of arrest(40), while other reports indicate access to a range of substances during incarceration(41). A study in an Ethiopian correctional facility found that 55.9% of incarcerated people had an active SUD during incarceration(42), while a similar study in a Kenyan correctional facility identified prevalence of cannabis use and alcohol use that were 21% and 65.1%, respectively(43). While limited data exists on the relationship between substance use and HIV among incarcerated persons in SSA, available data from the US shows that 28% of incarcerated PLHIV in one study reported hazardous alcohol use and 58% were drug dependent(44). Another study found that methamphetamine use among recently incarcerated PLHIV was independently correlated with decreased viral suppression(45). SUDs, particularly related to injection drug use, are a risk factor for HIV infection and may also be a barrier to HIV testing and treatment(46), with recent modeling data demonstrating that incarcerated people with a history of injection drug use are at higher risk for ART discontinuation both during and after release(12).

To deliver appropriately tailored client-centered mental health services, a granular understanding of the demographic composition of incarcerated PLHIV is valuable. While men comprise approximately 97%(47) of the incarcerated population in SSA, sparse data indicate that incarcerated females have higher rates of co-morbid HIV and depression(48) compared to their male counterparts(11, 49). While the reasons for this are unknown, it may be explained by higher background HIV and depression prevalence among women in the general population(50), by factors associated with both HIV and incarceration, such as sex work, or that incarcerated women come from the most marginalized segments of society, and thus face disproportionately higher risk of HIV and MHDs. Further, due to their relatively small numbers, women may be deprioritized in the planning and resourcing of correctional health services resulting in critical access barriers not experienced by men (51, 52).

Globally, juveniles in conflict with the law have been identified to have a high unmet need for sexual and reproductive health services, including for HIV, and mental health service(53), while reporting increased high-risk health behaviors, self-harm, victimization and suicide(54). A review of data on incarcerated juveniles in SSA found that only three countries in the region—South Africa, Mali and Equatorial Guinea—do not routinely imprison juveniles in the same facility as adults(54). Such practices expose juveniles to unnecessary risk for HIV through sexual violence and transactional sex, as well as MHDs via trauma and manipulation(54). As a result, studies have found prevalence of MHDs among juveniles in conflict with the law in SSA to be high(55). Any mental health intervention in a correctional system must consider these vulnerabilities and be able to identify and tailor services to juveniles in a way that meets their unique developmental and psychological needs.

Correctional System Organizational Characteristics

In PRISM, an organization’s characteristics can promote or hinder introduction of new services. In correctional systems in SSA and globally, organization culture typically prioritizes (understandably) security, and a rise in corporate culture and privatization in many correctional facilities can be detrimental to incarcerated people’s rights, including the right to health. While corrections systems may vary in how they structure their security measures, experiences with HIV and other health services in correctional settings have highlighted widespread access to care barriers (16, 21, 49). These challenges become particularly acute when corrections staff, including key mid-level facility managers, deny incarcerated people access to health services outside the correctional facility (when health services are not available internally) due to security concerns. Transposing such experiences to mental health, referrals for services would likely be challenging in circumstances requiring the incarcerated person to be escorted to a non-secure space (e.g. a mental health hospital or provider’s office). While there is need for policy change, broad organizational reform, and communication and support from senior corrections leadership to address these issues, in the interim, to reduce the logistical and security barriers involved with incarcerated PLHIV accessing mental health services, adaptable mental health interventions may need to be delivered within existing correctional facility infrastructure.

Organizationally, many SSA corrections systems are ill equipped to respond to the mental health needs of incarcerated PLHIV. Firstly, for any correctional system to support mental health intervention delivery, there needs to be a perception that it fits with the organization mission, and that the intervention will not be burdensome to the corrections system. Secondly, MHD services need to be viewed by corrections leadership at each level—central, regional and facility—as both useful and acceptable in a prevailing security-conscious workforce. Given that mental health is often poorly understood in mainstream, let alone correctional health systems, awareness building at all levels of the correctional service and advocacy for policy change should precede introduction of any mental health intervention for it to be considered necessary and acceptable(20, 56). Experiences with implementing HIV and TB/HIV services in SSA correctional facilities demonstrate how awareness building needs to extend beyond healthcare providers to include the entire corrections hierarchy, including frontline staff, managers, and leaders(16, 57). Not to do so risks critical situations in which incarcerated PLHIV are unnecessarily denied services, or mental health providers are unable to reach incarcerated persons in cases of life-threatening emergencies such as suicidal ideation (16, 58). Drawing upon parallels with HIV and highlighting opportunities to build mental health services into existing HIV service delivery platforms may create a more familiar starting pointing for building staff and leadership support for addressing the mental health needs of incarcerated people.

Correctional health systems in SSA typically experience chronic shortages of trained medical staff, health commodities, and information management systems, which limits organizational capacity to deliver health interventions, including for HIV and mental health(16, 49). In Zambia, a severe lack of healthcare workers limit the days and times when clinics are open to provide health services, and can contribute to negative perceptions among incarcerated people about the quality and responsiveness of these services(21). A paucity of health workers reduces the number of available medication prescribers and exacerbates already broken supply chain management systems in which even the most basic medications, such as ibuprofen(16), may be lacking. Finally, national health information systems for HIV and other priority conditions rarely include correctional facilities, making facility-level data scarcely available to monitor performance or understand the burden of HIV, MHDs, and other diseases among incarcerated people. Taken together, these constraints underscore the importance of advocacy to strengthen health policy, planning and resourcing in relation to correctional health services, but also the importance of designing pragmatic interventions capable of operating within these constraints in the short- to mid-term.

Evidence-Based Mental Health Interventions Relevant to Correctional Settings

Several evidence-based interventions exist that are relevant to addressing MHDs among incarcerated PLHIV in SSA. Generally, these interventions are designed to be implemented by lay healthcare workers, thereby reducing the resource and cost intensity of traditional mental health services provided by psychiatrists and clinical psychologists. Overall, these approaches seek to empower and involve clients with mental health disorders to shape their own care plan and integrate the services of peer providers as a support mechanism to encourage recovery and resilience (59). The interventions highlighted here seek both to address initial stabilization and long-term recovery for depression, anxiety, PTSD and SUDs (60, 61).

Two recent studies from US correctional settings point to effective interventions potentially adaptable to analogous SSA settings. The first study compared group sessions using manualized inter-personal therapy plus anti-depressant medication to anti-depressant medication alone; participants in the group session arm experienced a greater reduction in major depressive symptoms, hopelessness, and PTSD symptoms. The second study, one of meditative yoga, reported less psychological distress among participants receiving the intervention than among controls assigned to an exercise diary (62). In a small study of a similar intervention among PLHIV with co-morbid substance use newly released from prison in the US, 50% of releasees reported reduced substance use (or maintained non-use) and a similar percentage experienced reduction in stress and increased social support and confidence(63). Adaptation of these interventions to SSA correctional settings requires dedicated study.

Cognitive-Behavioral Therapy (CBT) approaches are a feasible and acceptable intervention that can be delivered by lay healthcare workers to support PLHIV in SSA(64–66). Intensive CBT approaches have been shown to improve depression symptoms and adherence to ART(67). Such approaches have resulted in an increase in psychological well-being scores among incarcerated people (regardless of HIV status) in Iran (68). Traditionally, psychologists and other professionals provide CBT in one-on-one sessions to clients. More recent work has sought to extend delivery of this intervention to group settings and via lay healthcare workers. One such approach is termed the “Common Elements Treatment Approach (CETA)” (67) in which lay healthcare workers deliver CBT. Although CETA has yet to be applied in a correctional setting, it has generated considerable evidence of being effective in reducing MHD symptoms(69, 70), as well as decreasing substance use(71) in a number of low- and middle-income countries, including Zambia(71). A study is currently underway in the Ukraine to establish whether a shortened five-session version of CETA, which front-loads elements considered to be the most impactful, is as effective as the current model. Such a condensed model, if proven effective, could have substantial utility for being integrated into existing HIV programming in correctional contexts in SSA where health worker staffing is limited, ART clinics are busy, and the duration of incarceration unpredictable(49).

Delivery of any mental health intervention must account for incarcerated PLHIV’s perspectives on patient-centeredness, minimize the complexity of receiving the intervention, and address access barriers. Incarcerated PLHIV’s willingness to participate in any intervention may be hampered by internalized or externalized stigma related to participating in a mental health intervention. Issues of trust and confidentiality, particularly in the context of providing talking-therapy or peer-led interventions, needs to be considered thoughtfully. Acceptability of attending any group or individual therapy session may also be hampered by “work” requirements in which incarcerated people are expected to conduct public works or field labor with little spare time as part of a “hard labor” sentence(72). Where work is not compulsory, many incarcerated people will prioritize such work as it may provide opportunities for physical activity, income generation, and/or a way to engage with the outside world.

Implementation Strategies for Integrated HIV-Mental Health Service Delivery

In this section, we highlight several key strategies and intervention elements relevant to feasibly integrating mental health interventions into existing HIV service delivery platforms that can account for prevailing resource limitations and health system constraints in SSA correctional settings. We organize descriptions of promising programs, emerging evidence, and the authors’ recommendations around established guidelines for specifying and reporting implementation strategies(73).

SSA correctional settings should look to lay counselors and incarcerated peer educators as the key actors for using a task-shifted strategy for intervention delivery, allowing for interventions to be delivered without depending on highly trained and scarce mental health professionals (i.e., psychologists, psychiatrists, etc.). Such a peer-led strategy builds on established programs that deploy peer educators to address HIV and tuberculosis (TB) in SSA correctional facilities(74, 75). Such peer educators have been instrumental in introducing several general health interventions for TB and HIV, including systematic TB screening and diagnosis(75) and universal test and treat (UTT) for HIV. Peer educators should receive training and mentorship, have a role in shaping facility-level health policy and practice, come from diverse backgrounds to match the demographics of the incarcerated population of interest, and be supervised by and held accountable to formal health structures with linkages to mental health professionals for more severe conditions like suicidal ideation(57).

Specific actions that could be undertaken by lay healthcare workers or peers encompass sensitization and mobilization of incarcerated PLHIV around mental health, using validated instruments to screen for MHDs, managing support groups, and directly delivering an evidence-based therapy (e.g. group CBT). In the only recently published evaluation of a peer educator-led mental health intervention, incarcerated persons in Nigeria were screened for depression and randomly assigned to either a 12-session, peer-driven Cognitive Behaviour Counseling (CBC) program or standard of care one-on-one counseling. Results showed that incarcerated participants exposed to peer educator group sessions reported significantly reduced levels of depression by 3 months compared to standard of care counseling(76).

Group-based services have also been implemented in a large Malawian correctional facility(77) that featured peer educators providing Motivational Interviewing (MI)-based support to all incarcerated people with mild to moderate depression. This model uses a tailoring and demand creation implementation strategy(73)—one that acknowledges the vital role that drama, song, religion and sport play in the daily life inside correctional facilities—to facilitate mental health discussions among incarcerated people (63). Such activities are a culturally acceptable and a low literacy-accessible mechanism to engage incarcerated people in difficult conversations around mental health and may help de-stigmatize participation in mental health interventions. While the mental health outcomes in the program have yet to be published, this care model has been accepted by the Malawian government as an effective model for how to provide integrated mental health and multi-disease services(78). The model combines the aforementioned MI-based mental health intervention with integrated screening and treatment for HIV, TB, and sexually transmitted infections, resulting in excellent viral suppression for incarcerated PLHIV, reported at 90.7%(79). Further research is needed to understand the effects of such integrated mental health interventions on other critical health outcomes for incarcerated PLHIV, including retention in care and overall survival.

Implementation of any model requires the approval of both formal and informal prison hierarchies. Informal prison hierarchies include cell captains, cell monitors, peer educators, and others who have been given special responsibilities or privileges. These individuals typically include some of the best educated among those incarcerated and can be integral to the coordination of healthcare services (where they exist) within the prison. Although not always ideal due to risks to confidentiality and abuse of power, experience with HIV, TB, and general health programs in SSA correctional facilities suggests that involvement of such ‘higher ranking’ individuals can be productive in some instances(15, 16, 21) Champions from these structures can be identified, trained, and carefully supervised to support a mental health program. The use of advisory boards and working groups (ideally drawing from a combination of incarcerated persons, corrections staff, lay healthcare workers, and mental health professionals) should be considered.

The release of an incarcerated person is a particularly important time to sustain the effects of integrated mental health and HIV interventions since it has profound implications for continuity of care for these co-morbid conditions. In one South African correctional facility, soon to be released incarcerated persons received an intervention providing peer-led group support sessions touching upon topics like alcohol and drug use, general life skills, and prevention and management of HIV/AIDS, among others. Six months after release, incarcerated persons exposed to the peer-led group intervention were more likely to express confidence in condom use and intention to reduce risky sexual behavior compared to controls who received basic counseling and health promotion information(80). Additional research from SSA correctional settings is needed to establish a strong evidence-based justification for this type of task-shifted, peer-led mental health intervention, and to examine effects on key steps of the HIV care cascade for releasees living with HIV.

Outside correctional facilities, emerging evidence from a variety of resource-limited settings provides some indication of the potential for implementing the peer-led program elements highlighted here. In urban India, a community-based, peer-led, Group Support Psychotherapy (GSP) intervention led to sustained improvements in anxiety and depression among a group of highly disadvantaged young women(81). A similar approach was evaluated in a study from rural Uganda where HIV-positive adults with mild to moderate depression were randomly assigned to either an active control arm consisting of group-based HIV education or an intervention involving six GSP sessions led by lay healthcare workers. The GSP sessions addressed coping strategies and goal setting and provided participants with training on income generating skills(82). At the end of the study, less than 1% of participants who received the GSP went on to be diagnosed with major depression compared to 28% in the control arm(82). Finally, available evidence on the effectiveness of correctional facility-based support-groups to address SUDs suggests that participation increases likelihood of recovery and, when support groups are integrated into post-release care, may be effective at reducing relapse and recidivism(83). However, sustained intervention effectiveness after release relies upon the availability of post-release transitional care, which is largely non-existent for both HIV and MHDs in SSA correctional settings.

Programmatic and Policy Implications: Where do we go from here?

In correctional facilities in SSA, it is difficult to envision substantive changes in the accessibility and quality of mental health services for incarcerated PLHIV without realizing a fundamental reorganization of priorities—one that provides the resources and infrastructure necessary to build up (currently scarcely available) mental health programming. Based on insights from PRISM, opportunities exist for leveraging recent investments in HIV programming for incarcerated PLHIV and other key populations to pursue more patient-centered and holistic primary health care models that sustainably integrate evidence-based interventions for common mental health disorders.

MHDs and their effects on incarcerated PLHIV must be the subject of sustained research and advocacy to improve knowledge and recognition of the scope and depth of the burden and the impact of these conditions on conjoint HIV and mental health-related clinical and implementation outcomes. Concurrently, investment in adapting, delivering, and evaluating evidence-based MHD interventions for incarcerated PLHIV, such as those treatment models and implementation strategies outlined here, would help raise awareness of the feasibility, acceptability, appropriateness, and maintenance of such approaches for all incarcerated people in SSA correctional settings.

Critical investment in building both specialist and generalist mental health capacity in the mainstream and correctional health systems of SSA, including in government and donor-funded HIV programs should be an urgent priority. Broader advocacy for greater funding and structural improvements across the full spectrum of disorders are needed for the following: more humane and modern holding facilities; well-integrated health information systems that articulate with mainstream health systems to assist with continuity of HIV and mental health care; improved health provider-incarcerated person ratios; and investment in improved pre-service and routine annual in-service health education and sensitization for all corrections personnel.

Finally, policy change is required not just within correctional systems, but also within the wider health community in SSA to shift away from solely managing acute episodes of mental illnesses to embracing a more holistic, longitudinal, and non-stigmatizing recognition of, and response to, MHDs, particularly for PLHIV. For example, there can be greater adoption of community-based programs, integrated within existing primary care and HIV service delivery platforms, to improve access to services for those MHDs that most frequently burden PLHIV in SSA, including for incarcerated PLHIV.

Conclusion

Addressing mental health disorders among incarcerated people, especially those living with, and at risk for, HIV remains an important service delivery gap that should be addressed. There are promising interventions employing task shifting and other implementation strategies that may be responsive to the needs and circumstances of incarcerated PLHIV and could be adapted for integration into existing HIV service delivery platforms in correctional facilities in SSA. However, additional implementation science-informed research is needed to help conceptualize, design, and measure integration of mental health services into corrections HIV programming, and assess clinical, health service, and implementation outcomes for promising interventions and strategies in such settings. Given the feasibility of providing HIV prevention, treatment, and care in many correctional facilities in SSA, and the urgent unmet need for mental health services among incarcerated PLHIV, there is no reason to believe that services for MHDs can’t also be provided in these same settings.

Table 1.

Evidence-based treatment interventions and implementation strategies suitable for correctional settings in sub-Saharan Africa.

Treatment Name	Treatment Type	Treatment Aim	Implementation Strategy	Common mental disorders and related symptoms and conditions with evidence for effectiveness
Cognitive Behavioral Therapy (CBT) (84)	Psychotherapy-based	Confront and modify negative thoughts, beliefs, attitudes and behaviors by encouraging patients to regulate their emotions and develop coping strategies	Task-shifting to peer-educators / lay healthcare workers Group-based delivery Adapting curriculum to local needs	Depression Anxiety Disorders Post-traumatic stress disorder Sleep disorders Substance use disorders Phobias Has also been shown to support patients suffering from: Stress Grief & Loss Emotional trauma related to abuse or violence
Interpersonal Psychotherapy (IPT)(85)	Psychotherapy-based	Change unhelpful interpersonal and social behavior patterns which can help reduce their distress. Conducted usually over a 12-week period	Task-shifting to peer-educators / lay healthcare workers Group-based delivery Adapting curriculum to local needs	Major depressive symptoms Feelings of hopelessness Post-traumatic stress disorder
Common Elements Treatment Approach (CETA) (60)	CBT transdiagnostic approach	Singular CBT-based approach (provided by modular, flexible 6–12 one-hour sessions) that address multiple common mental disorders and co-morbidities, including substance use	Group-based delivery Task shifting delivery to lay workers/peers Training on an established curriculum	Depressive symptoms Anxiety Substance use disorders Post-traumatic stress disorder
Cognitive Behaviour Coaching (CBC) (86, 87)	Personal coaching technique	Combines practices from CBT with solution-focused approaches driven by goal setting theory and social cognitive theory to support patients to ultimately become their own coaches	Task-shifting to peer-educators / lay healthcare workers Group-based delivery Adapting curriculum based on individual goal setting	Depressive symptoms
Yoga therapy (88)	Meditation-based therapy	Use yoga postures, breathing exercises, meditation, and guided imagery to improve mental and physical health	Task-shifting to peer-educators / lay healthcare workers Group-based delivery	Mild depressive symptoms Anxiety Stress
Motivational Interviewing(89)	Advanced counseling technique	Help patients and their families resolve ambivalence about engaging in a health-related behavior by using a non-confrontational style of communication.	Integration with HIV-screening & treatment Task-shifting to peer-educators / lay healthcare workers One-on-one counseling	Uptake of mental health services Adherence to ART Substance use disorders