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. Author manuscript; available in PMC: 2022 Jun 1.
Published in final edited form as: Soc Sci Med. 2021 Apr 29;279:113978. doi: 10.1016/j.socscimed.2021.113978

Mental Health in HIV Prevention and Care: A Qualitative Study of Challenges and Facilitators to Integration in Vietnam

Kathy Trang 1, An Thanh Ly 2, Le Xuan Lam 3, Carolyn A Brown 4, Margaret Q To 5, Patrick S Sullivan 4, Carol M Worthman 6, Le Minh Giang 3, Tanja Jovanovic 7
PMCID: PMC8684791  NIHMSID: NIHMS1704916  PMID: 34000583

Abstract

Introduction:

Globally, men who have sex with men (MSM) experience a disproportionate burden of mental health issues. While HIV service providers may possess the skills and relationships to provision mental health and psychosocial support (MHPSS) to this population, task-sharing models that integrate MHPSS into HIV contexts remain limited. The aim of this study was to explore the sociodemographic, psychological, and structural factors operant at the client and HIV service provider levels that shape MHPSS access and burden among MSM and opportunities for integration in Vietnam.

Methods:

Between June and August 2018, semi-structured interviews were conducted with 20 MSM and 13 service providers at out-patient clinics (OPCs) and community-based organizations (CBOs) in Hanoi, Vietnam. Interviews explored participants’ understandings of and experiences with the signs, causes, and appropriate treatments for mental health concerns; and perceived barriers to MHPSS integration in HIV contexts. Data were coded thematically and analyzed in MAXQDA.

Results:

Most MSM did not view their mental distress as constituting illness or as warranting clinical attention. Specifically, terms like “mental illness” were often associated with being “crazy” or immoral, while symptoms of distress were interpreted as having to do with everyday difficulties associated with being MSM and/or HIV-positive. Due to mental health stigma, MSM were reluctant to access services while service providers were similarly reluctant to query about needs. Few service providers knew where to refer patients for MHPSS, and none had done so previously. Most service providers reported lacking the human capital, expertise, and funding to address MHPSS needs.

Conclusions:

Our findings suggest that aside from mental health stigma, future integration strategies must address competing demands and incentivization structures, limitations in existing mental health infrastructure and funding, misperceptions around MHPSS needs and symptoms, and opportunities to streamline MHPSS with existing CBO activities to strengthen community wellbeing.

Keywords: HIV, Mental health, Men who have sex with men, Vietnam, Qualitative, task-shifting

1. Introduction

In 2016, over one billion people worldwide were estimated to be living with a mental health or substance use disorder (Rehm & Shield, 2019). Mental health disorders alone accounted for 7% of all disability-adjusted life years, constituting the largest disability burden of any disease category. Among people living with or at high risk for HIV, this burden is magnified (Collins et al., 2006; Heywood & Lyons, 2016; Nanni et al., 2014; Walkup et al., 2008). In the context of HIV, mental illness reduces adherence to antiretroviral therapy (ART) and pre-exposure prophylaxis (PrEP), increases the likelihood of engaging in HIV transmission risk behaviors, and elevates the risk of virologic failure among those HIV-positive (Collins et al., 2006; Uthman et al., 2014). Concomitantly, due to its psychosocial and biological effects, people living with HIV (PLWH) may also be at an increased risk for developing a range of mental health and neurological disorders (Arseniou et al., 2014; Chaudhury et al., 2016; Wright et al., 2008).

The World Health Organization (WHO) estimates that an addition of over one million mental health workers is necessary to close the overall treatment gap (i.e., disparity between the number of individuals who need mental health treatment and those who receive it) (Fulton et al., 2011; Lora et al., 2011; Patel et al., 2010). Task-sharing, or the transfer of tasks normally performed by specialized health professionals to general health professionals and community workers, has been found to be a promising strategy to meet those demands. Task sharing is associated with improved screening and disease outcomes, decreased stigma associated with specialized care, and reduced loss of individuals during the referral process (Joshi et al., 2014). Freeman and colleagues (2005) have argued that the burgeoning number of primary care providers and community workers, who are equipped to conduct pre-test and post-test HIV counselling, possess the skills and relationships to treat mild psychological distress among this population and make referrals to mental health services (Collins et al., 2006; Freeman et al., 2005). Despite this promise, interventions and approaches to integrate mental health and HIV services remain lacking generally and in Asia specifically, where approximately 5.8 million PLWH reside (Chuah et al., 2017; Esposito et al., 2009; T.T. Thai et al., 2017).

Vietnam is a case in point: In 2018, there were approximately 230,000 PLWH in the country (USAID, 2018). From 2010 to 2018, expansion of HIV testing and treatment contributed to a 45% reduction in AIDS-related deaths and a 65% drop in new HIV infections, respectively (USAID, 2018). Despite strides in HIV prevention and intervention, psychosocial problems continue to be overrepresented among men who have sex with men (MSM), which refer to a category of men who—irrespective of sexual orientation—have same-sex sexual relations (Young & Meyer, 2005). An estimated 19%−58% of MSM meet criteria for a common mental health disorder (Biello et al., 2013; Esposito et al., 2009; Goldsamt et al., 2014; T.T. Thai et al., 2016). While higher bound estimates may be driven by high-risk MSM not engaged in health services, our research team has found that even among Vietnamese MSM accessing HIV services, an estimated one-fourth to one-third meet criteria for depression, anxiety, and post-traumatic stress disorder (Anonymous, unpublished results).

Given the dearth of literature examining perceptions of mental health in HIV prevention and treatment contexts in low-and middle-income countries (LMICs), this paper sought to critically examine the factors that either facilitate or impede MSM’s access to and utilization of mental health and psychosocial support (MHPSS) services in Vietnam. A review of the extant literature examining MHPSS utilization in the country identifies the paucity of skilled professionals; availability of services, particularly in rural areas; and low mental health literacy among the general population as primary barriers to treatment (Giang et al., 2010; Dang et al., 2018; D.T. Nguyen et al., 2020a; Q.C.N. Thai & Nguyen, 2018; van der Ham et al., 2011; Vuong et al., 2011; Weiss et al., 2011). At the individual level, research drawing from the Health Belief Model has identified education level, age, gender, and inability to recognize mental health problems as key demographic and psychological characteristics impeding help-seeking behaviors (Kamimura et al., 2018; Laqua et al., 2018; T. Nguyen et al., 2019; Peltzer et al., 2016; Q.C.N. Thai & Nguyen, 2018; van der Ham et al., 2011). As our sample consists of both MSM receiving HIV services and their service providers at community-based organizations (CBOs) and out-patient clinics (OPCs), this study provides unique perspective into the contributions of the aforementioned sociodemographic, psychological, and structural factors operating on both sides to shape MHPSS access and continued mental health burden among this group in the context of HIV care.

2. Materials and methods

2.1. Study design.

Participants in this study comprised MSM receiving ART or PrEP and their HIV service providers at CBOs and OPCs in Hanoi, Vietnam. This study was embedded into a larger project examining the predictors and consequences of mental health burden among young MSM (ages 18–29). A purposive sampling strategy, commonly used in qualitative research to maximize diversity in important participant attributes, was used to select individuals based on factors known to impact beliefs about or experience with mental distress in Vietnam: (i) rural-urban migrant status, (ii) age, and (iii) serostatus (Biello et al., 2013; Ta et al., 2016). Eligibility criteria for MSM included being 18 years of age or more, having had anal sex with another man within the past six months, and (a) if HIV-positive, be receiving ART; or (b) if they were HIV-negative, be on PrEP. Given that all participants were receiving HIV-related services, the majority interacted with CBO or OPC staff at least on a monthly basis. Through consultations with collaborators at Hanoi Medical University (HMU), service providers at CBOs and OPCs were selected based on their involvement in provisioning HIV-related services (e.g., lay provider testing) and their experience working with a large MSM demographic.

Interviews were conducted face-to-face at HMU or, in the case of service providers, at their organization between June and August 2018. Most interviews were conducted in Vietnamese (n = 30/32) by the first author and her research assistants, and 2 interviews were conducted in English (by CAB and MQT). Each interview was conducted privately. None of the interviewers were previously familiar with the interviewee. All research assistants were provided with training on conducting interviews, mitigating psychological distress during interviews, and ensuring study confidentiality. An interview guide was created in English then translated into Vietnamese by study staff (KT and ATL), and initial interviews were conducted in teams of two to standardize protocol. In addition to sociodemographic background, open-ended interview questions probed participants’ beliefs about the signs, causes, and appropriate treatment for mental illness, and the impact of psychosocial distress on HIV risk. Since two of the authors (KT, ATL) have worked extensively with MSM populations over the past five years and one (ATL) has been professionally engaged in HIV health systems in Vietnam over the past decade, they were able to draw upon their experiences in designing the research protocol. Interviews were audio-recorded with consent.

2.2. Data analysis.

Interviews were transcribed verbatim and anonymized by two research assistants then imported into MaxQDA (VERBI, Berlin, Germany), a qualitative data analysis software. Three of the authors (KT, ATL, and LXL), who were bilingual, then independently reviewed the transcripts and generated preliminary codes before meeting to refine primary and secondary code definitions. Once the codebook was established, two analysts coded each transcript. Routine checks of inter-coder consistency were performed and maintained at the >0.80 level. Discrepancies between coders that could not be reconciled were settled by a third coder. After all transcripts were coded, the authors (KT, ATL, and LXL) then met to review excerpts and identify salient themes. Quotations were selected to illustrate the major themes and sub-themes.

2.3. Ethics statement.

This study was approved by the Institutional Review Boards for Emory University (IRB00097736) and HMU. Study staff provided participants with a copy of the consent form and went through each section with the participant to ensure comprehension and to provide opportunities for questions. Written consent was obtained. During the consenting process, it was emphasized more than usual that study participation was entirely voluntary, and all data would be kept completely confidential. Their decision to participate would not impact the services they received (in the case of MSM participants) or their evaluations by superiors (in the case of service providers).

3. Results

3.1. Participant characteristics.

Sociodemographic characteristics of participants are shown in Table 1. In total, 20 MSM and 13 CBO and OPC staff participated in the study. MSM participants ranged from 20 to 29 years old; most had graduated from university and were employed full-time. The age of OPC and CBO staff ranged from 23 to 59 years old. All OPC staff had completed a university education, while educational attainment was more variable among the CBO staff who also tended to be younger and themselves MSM. Although all OPC staff were employed full-time, approximately half (3/7) of the CBO staff either worked part-time or were independent contractors. Levels of experience varied across CBO and OPC staff with most (8/13) having provided HIV services continuously over more than five years and others (2/13) having started less than a year ago. Interviews ranged from 40 to 111 minutes.

Table 1.

Sociodemographic characteristics of men who have sex with men (MSM) and service providers at out-patient clinics (OPC) and community-based organization (CBOs) interviewed, n = 33.

MSM (N= 20) OPC (n = 6) CBO (n = 7)
N (%) or mean
Age
 Mean 24 39 25
 Range 20–29 27–59 21–31
Education
 High school or less 7 (35%) -- --
 Some university 6 (30%) -- 2 (29%)
 Graduated university 7 (35%) 3 (50%) 4 (57%)
 Postgraduate education -- 3 (50%) 1 (14%)
Job
 Part-time 3 (15%) -- 2 (29%)
 Full-time 15 (75%) 6 (100%) 4 (57%)
 Independent 2 (10%) -- 1 (14%)
Income
 Less than 5 million VND 1 (5%)
 5 million-8 million VND 10 (50%)
 8 million VND and above 9 (45%)
Serostatus
 HIV-positive (on ART) 10 (50%)
 HIV-negative (on PrEP) 10 (50%)
Length of time on ART/PrEP
 Less than 3 months 8 (40%)
 3–6 months 4 (20%)
 More than 6 months 1 (5%)
 More than one year 7 (35%)
Years working in HIV field
 One year or less 1 (17%) 1 (14%)
 Between 1 and 5 years -- 2 (29%)
 More than 5 years 5 (83%) 4 (57%)
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3.2. Beliefs about mental health.

Most of our MSM participants reported not having been previously exposed to information related to mental health or mental illness. When asked about their beliefs about mental health, MSM interviewees often distinguished between a more severe presentation of mental illness that was due to damages to the nerves (thần kinh) versus a mild, moderate presentation of mental illness that focused on psychosocial distress (examples below):

“It’s like if you encounter stress in your life and you can’t control your mental state (trạng thái).”

– 29-years-old MSM, HIV-positive

“Mental illness (bệnh tâm thần) has to do with problems in the nerves (thần kinh), which become unstable compared to those of a normal person, and this causes abnormal behaviors.”

– 23-years old-MSM, HIV-negative

Between the two, severe definitions were more commonly provided. Dysregulation of thần kinh was thought to contribute to unstable, erratic behaviors, paranoia, and hallucinations. Some believed that these neurological difficulties were temporary, representing only a period of heightened vulnerability; participants considered a transition to being “crazy,” or điên, to be more permanent. Although few interviewees could offer an explanation for the transition to being điên, most thought those who were điên were unable to abide by moral or legal regulations of everyday life. Criteria for what constituted điên were diverse, but commonly included references to someone the interviewee had either known or heard about who had a history of “crazy outbursts,” eventually culminating in criminal behavior.

“There are some with neurological disorders (vấn đề thần kinh) with a history of being điên. I have spoken to someone like that before. When I spoke to this person, I saw that he sometimes would speak, would act, in a way that differs a bit from others, but at the time, I felt it was normal. The person didn’t say anything that was too off… He just had too much of an attitude… That person was mentally ill (bị bệnh tâm thần) and had điên episodes already. And I knew that, but I still spoke to him normally …. It was still within the limits I was able to accept, but I don’t know [how he is] during a điên episode. Do you know about the case of the guy who slammed the window shut on his girlfriend’s head and killed her? I have spoken to him before and used to go drinking with him… He was also someone who was mentally ill (tâm thần) and had a history of being điên.”

– 25- years-old MSM, HIV-positive

Due to this emphasis on severe manifestations of mental illness, when asked to describe signs or symptoms of illness, some interviewees did not believe that it was possible for normal people like them to come into contact with someone who was mentally ill. Specifically, participants often believed those who were mentally ill would be diagnosed early on and institutionalized:

“Around the place I live and among those I know, no one is mentally ill (mắc bệnh tâm thần), so I don’t know a lot about mental health and haven’t Googled to see what mental illnesses (bệnh tâm thần) are or what to do if I were to interact with people like that. There are cases of mentally ill people (người tâm thần) who have a điên episode then go and butcher other people, which I have read about a bit, and afterwards, Googled to see if there were preventive measures, but that didn’t go anywhere. Since I don’t know anyone mentally ill (bị tâm thần), I just forgot about it.”

– 26-years-old MSM, HIV-negative

Still, most MSM participants also recognized that there were more mild or moderate forms of mental distress that a person could experience, having to do with alterations to their psychological or mental state. This distress manifested as muddled thinking, delayed reaction time, poorer memory, unstable or unpredictable thoughts or behaviors, and excessive worry. Those who had recently been diagnosed with HIV were thought to be particularly vulnerable to this level of mental distress.

However, despite their elaboration on potential indicators of mental illness, most participants believed that it was difficult to tell if someone was mentally unwell because people with mental illness would try to conceal it; mental health issues were believed by participants to be not something to be discussed. Several participants repeatedly differentiated between mental illness (bệnh tâm thần) and mental health (sức khỏe tâm thần) and between mental (tâm thần) and psychological (tâm lý) health, with the former often carrying more negative connotations.

3.2. Experiences with and causes of mental distress.

Most of our MSM interviewees reported never having experienced what they perceived to be signs or symptoms of mental illness. In spite of this, the majority (n = 17/20) reported experiencing significant psychological distress either in the past (nPrEP = 2/7; nART = 10/10) or in the present (nPrEP = 5/7; nART = 6/10). Approximately one-third also reported a history of suicidal ideation or self-harm, and more, depressive-anxious symptoms.

The sources of their distress were variable, but often centered on the precarious financial, familial, and romantic conditions associated with being a young sexual minority man in Vietnam. Among HIV-negative interviewees, psychological distress most often centered on rumination over their HIV risk and problems in their romantic or familial relationships. Several HIV-negative interviewees had initiated PrEP after their partner had been unfaithful and diagnosed with HIV, while other participants reported suicidal feelings after arguments with their partners or seeing their relationship cause familial tension. Sexual stigma was thus a major stressor in their lives. In addition, financial security was another major stressor, as many of the young men we interviewed did not have a stable source of income.

“Like with my partner, for instance. At first, I thought this person was 100% faithful towards me, but that wasn’t the case. After that time, I realized nothing was certain.”

–29-years-old MSM, HIV-positive

For those living with HIV, this stress was typically exacerbated by their diagnosis. Although nearly all interviewees who had been diagnosed with HIV reported experiencing significant mental distress initially, the persistence of mental distress among this group was often dependent on the degree to which HIV impacted their social and professional life, rather than their physical health. In particular, many feared that they might accidentally infect their family or fail to achieve stability in their romantic life (e.g., partners leaving after learning about their serostatus). One interviewee also disclosed having to forfeit his scholarship to study in South Korea after being diagnosed with HIV, while another struggled to find employment altogether, carefully selecting companies that did not require health examinations.

“Of course, I see my physical health improving, but psychologically, I am trying. In terms of being worse off, well, since the day I found out, most opportunities have closed [for me]. Before I was given an opportunity to go to South Korea, but then I read their policies for granting visas…. They won’t test whether you have HIV if you request a 90-day traveling visa, but if you request a residency permit for study or for work, then they [will require] it. So, I had to abandon my plans and switch to Europe, [which is] a harder target.”

– 23-years-old MSM, HIV-positive

A while back, I applied to [this big hospital in Hanoi], and they required [HIV] testing. It’s certain that if you apply to work in the hospital and are infected, you’d be eliminated….Labs that do genetic testing do not seem to require this. Sometimes they will have loopholes where they will accept the medical documents you purchase on the market, so it’ll be easier. For sure that if you worked at a bigger center, they will require [testing]. Normally, I will avoid those places.

–25 years old, HIV-positive

3.3. MHPSS Options – Patient Perspective

Only 2 of 20 MSM we interviewed had previously sought MHPSS services, and both claimed they were unable to locate any.

I have searched for mental health services before, but I have yet to find them…. The reason [I sought out those services] is because I thought my situation was unchanging for a long time, and I was not able to overcome [it]; so, I was forced to find someone to talk to and to give me advice to get better. I don’t know where to find those services. Even at the hospital, currently, they do not have a separate psychiatric unit, and I think in Vietnam, those services don’t exist. I still have not been able to find a service like that, and I have never heard about people who have needed those services finding them.”

– 24 years-old MSM, HIV-positive

This low percentage can be attributed to several pervasive beliefs. Some distrusted health professionals because they either had personally experienced or had known others who had been forced into conversion therapy. Others thought the psychological distress they experienced did not fall under the purview of “mental health.” Some participants, particularly those who reported a history of suicidal ideation, argued that they did not seek treatment because they feared answering questions about themselves and believed that the issues they experienced had to be independently overcome.

“[Once] my boss gave me a questionnaire with 54 items to test for depression. My score was also rather high. The day after I took the test, I told [my boss] I didn’t need to see a doctor anymore. Even though I actually needed it, I know that even in social relationships, I need to be close [with the person] to be able to confide in them…. Those who are depressed often create a shell for themselves so others will not know how they are.”

– 25-years-old MSM, HIV-positive

Lastly, some participants argued that they did not believe MHPSS issues and services were as applicable or as well addressed in developing countries such as Vietnam versus higher-income countries. Most of our interviewees emphasized that people they knew generally lacked the mental health literacy to attribute their symptoms to mental health issues and would instead perceive their symptoms as related to physical illness.

“It’s because Vietnam is not as developed as other countries. Developed countries will often have separate doctors. They will have this and that organization. Everyone will have a problem and they will talk to many people about that problem, but in Vietnam, first, our economy is not as well developed. We are not able to utilize separate doctors. Second, because our working age is higher, people will concentrate more on problems related to work, working, and making money.”

– 29-years old MSM, HIV-negative

Therefore, it was not uncommon for participants to believe that the only times when mental health interventions were warranted were when the person needed medication, including for neurological problems and—in some cases—when a traumatic life event (e.g., divorce) occurred and triggered a vicious cycle of “thinking a lot.”

3.4. MHPSS Options – Provider Perspective

Service providers were often aware of the mental health stigma among their patients and were thus reluctant either to raise issues related to or to use terms suggestive of mental illness in their consultations:

“One of the weaknesses of Vietnam is that when you mention mental illness (bệnh tâm thần), people will often think of some kind of [big] illness. Even if a person is very stressed and frequently feels tired, misses meals, and loses sleep, for example, if you offer refer them to a mental health professional, they will think differently and not want to do so because they will think of mental illness (bệnh tâm thần) as this loss of self-control or as something equally severe.”

38-years old OPC physician

Many CBO and OPC staff reported relying on indirect strategies to assess mental health status, such as general inquiries into their recent stress levels and relationship history, although the latter was often probed to assess HIV risk, rather than mental health. Although neither CBO nor OPC staff reported difficulty in eliciting this information, they found determining when and how to suggest referrals, treatment, or another form of intervention to be challenging:

“[Mental health fields] are not yet recognized as a legitimate profession with degrees and licenses. As society develops, mental health issues are growing, and maybe its growth means there is opportunity to seek services. But actually, few of those services are available in Vietnam. The psychology of Vietnamese people is such that when they are sick, only when they are really sick, do they seek treatment. But if they feel they can still self-manage, still endure, [then they won’t]. That’s the case for physical health, too, never mind mental health (sức khỏe tâm thần).”

– 27-years-old OPC staff

When evaluating whether someone had mental health issues, service providers reported attending most commonly to the following symptoms: self-harm behaviors, poverty of speech (lacking spontaneity or detail), inattention, excessive worry, confused or jumbled speech, insomnia, or sudden mood changes. For many OPC staff, this list of symptoms derived from their having worked with intravenous drug users (IDUs) who were more likely to present in an altered cognitive state. Due to these screening targets, MSM who do not use drugs may be less likely to be flagged as needing MHPSS services. So, too, a number of OPC staff believed that their MSM clients were more psychologically resilient than IDUs and other risk groups due to being younger and more educated. CBO staff, meanwhile, had greater immediate understanding of their client’s sources of distress and history of self-harm behaviors through their use of social media for outreach. When asked about mental distress among MSM, both CBO and OPC staff tended to provide examples of HIV-positive cases, and some stated explicitly that they thought mental health burden was disproportionately higher among ART compared to PrEP users.

In addition, many OPC and CBO staff prioritized ensuring that those diagnosed with HIV were connected to treatment as quickly as possible. In practice, this meant that many avoided questions they believed would either exacerbate worry or engender social friction. Staff recognized that the periods prior to and after diagnosis were stressful for their clients, and they saw quelling their clients’ anxieties about taking medication as primary. For similar reasons, rather than referring those who needed MHPSS services to specialized care, CBO staff felt more comfortable referring to other CBOs, which were perceived to have more resources, albeit not necessarily more MHPSS training than they did.

“Services are available, but [MSM] don’t want it; [they] won’t go. Those existing services will often rely on community members. Normally [I] won’t direct clients to hospitals because many [of my clients] are college students, and the fees there are high. Aside from that, if the hospital that I refer them to doesn’t do a good job, then I feel ashamed. So, often I will refer them to other CBOs.”

–27-years-old CBO staff

Funding allocation and work demand often placed additional constraint on the amount of support providers felt they could give. CBO staff, in particular, reported having little autonomy over their work schedule, because they were often tasked to conduct social media outreach, counsel clients at odd hours, and complete an ever-growing number of reports to coordinate with other domestic and international service providers and grant agencies. Below one staff member elaborated on the mental distress he has experienced as a result of the overwhelming amount of work he had, an experience that was not uncommon among others we interviewed:

It’s like an addiction. Perhaps not an addiction, but it’s become a habit to work without regard for time, without regard to location. [I] still message, still counsel, still ask how people are. [I] am still in contact, and now I feel . . . I feel I don’t have the time to rest or to eat. Sometimes even when I eat, [I] still message and answer people if they reply or ask; it could be [midnight] and if they ask, I’d still respond. But I feel that now I must fix that because people only have so much time and if you’re constantly working like that, then your health will be severely impacted; and I’m experiencing that [impact].

– 27- years-old OPC staff

As most—if not all—of the funding CBOs received was specific to HIV outreach and treatment referrals, the staff we interviewed often felt that they did not have the resources to provide additional MHPSS. Thus, even though some CBO and OPC staff mentioned the possibility of referrals to specialists and non-specialists for MHPSS, given the workload, receiving CBOs were not likely to be better staffed, and follow-up across entities was limited. None of the OPC staff we interviewed reported previously making such a referral, and CBO staff were much less likely than OPC staff to know where they could refer clients.

“I don’t have so much time that I can just initiate contact with clients. If they have problems, then they will contact me, and I will reply….I don’t know which one has a problem; I have so many clients. For example, if there are 200 clients and I had to contact them myself, then my salary does not cover contacting people and seeing if they have problems, doesn’t cover counseling them, or the phone costs associated with doing so. Secondly, doing something like that would increase work-related stress and create a lot of problems.”

– 32-years-old CBO staff

4. Discussion

Our interviews underscored that most MSM did not view their mental distress as constituting illness or as warranting clinical attention; terms like “mental health,” “mental illness,” or “mental disorder” conjured images of being điên, detached from reality, and unable to abide by any moral or legal regulations. Symptoms like tiredness, social withdrawal, or stress often fell instead into a second register having to do with responses to life adversity and the ability to be resilient. Given this differentiation, many were reluctant to access MHPSS services, regardless of need. Service providers and MSM alike characterized the pronounced stressors sexual minorities in Vietnam experienced, which an HIV diagnosis only exacerbated. While both MSM and service providers acknowledged the heightened mental health vulnerability post-diagnosis, CBO and OPC staff feared stigmatizing their clients and jeopardizing the already tenuous relationship on which motivating patients to initiate ART depended by querying on MHPSS needs. The lack of human capital, expertise, and targeted MHPSS funding further detracted from those efforts.

Findings corroborated previous reports of pronounced mental health stigma within Vietnam. A survey in rural and urban Hanoi found that one-third of respondents believed that most people would view being admitted to a mental hospital as a personal failure (Ta et al., 2016). Less than half thought that someone who had been in a mental health hospital would be perceived as equally intelligent or trustworthy as any other. This stigmatization was more pronounced in urban settings, a difference the authors attributed to the greater difficulty of securing employment and sustaining a meaningful social role when mentally ill. The majority of respondents also supported forced institutionalization of individuals who were suicidal, violent towards others, afflicted by persecutory hallucinations, or too socially withdrawn (Laqua et al., 2018). These beliefs were mirrored in a sample of Vietnamese college students, suggesting that they were not restricted to older populations (Kamimura et al., 2018). Given this stigma, clinical emphasis on somatic symptoms or cultural syndromes, which are more aligned with local experience and interpretation of mental distress, may increase MSM’s willingness to engage with MHPSS services and strengthen, rather than threaten, patient-provider communication and relationship (Kohrt & Hruschka, 2010). With the expansion of global mental health, locally adapted or developed instruments have become increasingly common in assessment and intervention, and overwhelmingly they appear to improve the accuracy of assessing functioning and psychopathology (Cork et al., 2019). In Vietnam, “thinking a lot,” orthostatic dizziness, headache, and bodily weakness have previously been identified as culturally salient symptoms that are also highly correlated with anxious-depressive symptomatology (Hinton et al., 2018).

Beyond stigma, our findings suggest that future integration of MHPSS services into HIV programs in Vietnam must also attend to (i) competing demands and incentivization at the provider level, (ii) inadequacy of existing mental health infrastructure, (iii) misperceptions around MHPSS needs, and (iv) opportunities to streamline MHPSS with existing CBO activities and services. First, as the interviews with HIV service providers highlighted, staff at OPCs and especially at CBOs felt taxed to meet existing demands and expressed reservations about what provisioning of MHPSS would require. Recent expansion of telehealth within Vietnam and elsewhere has invariably placed the brunt of associated costs (e.g., after-work hours to conduct outreach) on low-paid health workers (Hampshire et al., 2017). Studies evaluating initiatives that integrate MHPSS and HIV services yield promising results, but also underscore formidable barriers (Chibanda et al., 2015; Chuah et al., 2017; Kaaya et al., 2013; Udedi et al., 2018).

Scaling MHPSS infrastructure and ensuring sustainable knowledge transfer and practice necessitate mobilization of financial resources and careful attention to staff recruitment and retention to avoid “task-dumping” (Kakuma et al., 2011; Kottai & Ranganathan, 2020). Lessons from task-shifting in other low-resourced settings draw attention to two areas that appear primary vis-à-vis our findings: First, HIV service providers should be involved early on to clarify any changes to their roles and responsibilities in the event of MHPSS integration. Second, task-shifting must contribute to reduction in overall workloads to motivate buy-in and ensure quality of care. This may necessitate the creation of new incentivization structures and dedicated staff positions to avoid bottleneck situations in which new responsibilities are constantly offloaded to frontline workers who lack the support and supervision to provide quality care (Mijovic, McKnight, & English, 2016; Shidhaye et al., 2019).

Donors play a critical role. Historically, the President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria have financed the majority of HIV-related programming in Vietnam (Pallas & Nguyen, 2018). Since Vietnam attained its middle-income country status, external funding for HIV, alongside investments from the central and provincial government, has waned (H.T. Nguyen et al., 2020b). While creating newfound pressure, these developments have also contributed towards innovative mitigation strategies that can facilitate the integration of MHPSS into HIV services particularly at the CBO level. Currently, 17 CBOs are registered with Vietnam Union of Science and Technology Associations-Global Fund while others are self-managed (Tran et al., 2020). Donors preferentially want to engage CBOs as implementation partners. However, because CBOs are not legally recognized, donors often have had to work through Vietnamese NGOs (VNGO), which were legally registered. Under this structure, CBOs were often contracted by a single VNGO and siloed into separate niches with little incentivization to collaborate.

Scarcity of funding has encouraged CBOs and VNGOs to expand the scope of their activities to improve efficiency and, in theory, to follow donor priorities (H.T. Nguyen et al., 2020b). So, too, a growing number of CBOs have registered as social enterprises to generate revenue through their health services and other activities, making them eligible to receive external funding. As PEPFAR, WHO, World Bank, and UNAIDS have increasingly signaled interest in addressing MHPSS in the context of HIV (Collins et al., 2020), CBOs and OPCs that have preexisting relationships with key populations emerge as particularly attractive partners. From the perspective of the central and provincial government, integration of MHPSS into HIV care may be attractive not only in the short-term due to the availability of donor support, but also in the long-term as Vietnamese ministries push for horizontal service delivery and coordination between HIV and other health services (H.T. Nguyen et al., 2020b). However, as our study results highlight, assumption that CBOs and OPCs will readily take on these roles may be misplaced. Even as HIV funding wanes in Vietnam and worldwide, it remains the dominant source of global health funding (Woelbert et al., 2020). Therefore, as organizations look to expand and streamline services, it is possible they may lean into areas in which they have had previous experience and avoid those they may perceive, as some of our interviewees did, to jeopardize their relationships with key populations. Successful integration thus requires that donors work with the Vietnamese government to reduce mental health stigma at both the patient and provider level and strengthen MHPSS capacity.

Second and related to the above points, HIV service providers in OPCs and CBOs in Vietnam generally do not have experience with MHPSS. This reflects both the state of MHPSS in Vietnam today and in global health more generally. Mental healthcare in Vietnam is principally delivered at 27 provincial psychiatric hospitals and departments (Ng et al., 2011; Niemi et al., 2010). In 2000, the Vietnamese government moved to widen access to mental healthcare by introducing the National Community Mental Health Program to provide mental health screening and treatment in primary healthcare settings at the commune level (Ng et al., 2011). However, the program covered only 64% of the population and primarily targeted schizophrenia and epilepsy. Our findings suggest that CBO and OPC staff may be natural candidates for the delivery of MHPSS to key populations, but task-shifting would require investment in developing human capital and change in current funding priorities. General physicians at OPCs receive an average one month of psychiatry training as part of their medical school curriculum (Niemi et al., 2010); none of the OPC staff interviewed have since had supplemental training. Similarly, none of the CBO staff reported having received MHPSS-relevant training outside of HIV-related counseling.

Third, our interviews with service providers, particularly at OPCs, uncovered widespread assumptions that mental health burden was lower among high-risk, HIV-negative MSM compared to HIV-positive MSM; and among MSM relative to other risk groups (e.g., IDUs). Our team has not found any meaningful differences in trauma exposure or mental health burden among Vietnamese MSM based on serostatus (Anonymous, unpublished results), suggesting that service providers may inadvertently neglect HIV-negative MSM with equally pronounced MHPSS needs. The symptoms service providers reported attending to may additionally reflect their training in and overwhelming experience working with IDUs thus far. Future integration strategies should therefore attend both to the general lack of MHPSS experience among this group as well as their existing biases, which can influence screening of symptoms and detection of cases.

Lastly, understandings of MHPSS needs among MSM and service providers alike largely adhered to a social determinants of health perspective: Many of our interviewees recognized the pronounced sexual stigma MSM experienced and the potential of HIV in exhausting already taxed coping capacities. This insight was particularly evident among CBO staff whose work often necessitated that they had intimate knowledge of their clients’ lives. Given the pre-established trust between MSM and their HIV service providers, integration of MHPSS into HIV services may provide a means of addressing what many MSM themselves consider to be priority concerns in their lives. Within the past decade, CBO services in Vietnam have emerged as key actors in advocating for gender and sexual minority rights, strengthening community capacities and connection, and provisioning HIV-related services (Horton, 2014; Paul & Helle, 2020; Vu et al., 2018). While many MSM hesitated to seek specialized mental health services, few felt reluctant to seek the advice of CBO staff for what they perceived to be community (i.e., MSM-related) and HIV-related concerns. Integration of MHPSS into HIV services thus may provide a dual means of addressing currently neglected mental health needs among MSM while also pinpointing the underlying social and structural concerns emerging at the intersections of being MSM and HIV-positive in Vietnam that can orient future CBO activities.

4.1. Strengths and limitations

Study strengths include our examination of MSM’s perceptions of and experiences with mental health and MHPSS services in Vietnam, alongside perspectives from HIV service providers. Results highlighted not only the reluctance service providers felt in querying about MHPSS needs and the biases they held, but also the structural and sociocultural barriers many confronted in provisioning care.

Several limitations must be acknowledged. Given the focus on integration of MHPSS into HIV services, we had interviewed Vietnamese MSM who were currently on ART or PrEP. While we reached theoretical saturation, study findings may not generalize to more socially disadvantaged MSM, including those in peri-urban or rural areas of the country, among whom familiarity with, access to, and retention in health services are likely lower (Green et al., 2018). In An Giang, a semi-rural district in Southern Vietnam, for instance, only 19.2% of MSM have been tested for HIV in the previous year (Q.D. Pham et al., 2012). Mental health burden and stigma will likely be amplified in these settings, while rapport between MSM and service providers may be more challenged. As provincial governments are increasingly tasked with financing their own health programs, these regional disparities will likely become more pronounced. Given our study demographics, the perspectives of older MSM may also not be fully reflected. Third, while we inquired about mental health history, we did not use a screening tool to determine mental health symptoms at time of interview. While we did not find any differences in mental health beliefs among those who reported history of suicidal ideation and attempt and those who did not, it is possible that beliefs about and experience with mental health and MHPSS services may differ by symptom burden (Andrade et al., 2014).

5. Conclusion

Our findings demonstrate the pronounced need for MHPSS services in the context of HIV prevention and treatment. Individuals recently diagnosed with or at high-risk for HIV are vulnerable to mental distress, but a number of current structural, psychological, and cultural factors significantly impede their receipt of appropriate MHPSS. OPC and particularly CBO staff have established relationships with MSM and are among the first they turn to for social support. Therefore, with appropriate training and funding assistance, we believe they are feasible and appropriate targets for delivering MHPSS interventions to this population.

Highlights.

  • MSM engaged in HIV services are often unaware of available mental health services.

  • Mental health stigma must be addressed to integrate mental health into HIV services.

  • HIV service providers have misperceptions about mental health burden.

  • Attention to sociocultural context can facilitate assessment and intervention.

  • Donors play a key role in the integration of mental health care into HIV services.

Acknowledgements

The authors would like to thank the staff at Song Hanh Phuc and Center for Training and Research on Substance Abuse-HIV at Hanoi Medical University for their research support. The authors would also like to thank Nguyen Kim Chi and Nguyen Cong Thanh for their assistance with data collection.

Footnotes

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Credit Author Statement

Kathy Trang: Conceptualization, Methodology, Formal analysis, Investigation, Writing – Original Draft, Funding acquisition. An Thanh Ly: Formal analysis, Writing – Original Draft, Project administration. Le Xuan Lam: Formal analysis, Investigation, Writing – Review & Editing, Project administration. Carolyn A. Brown: Conceptualization, Methodology, Formal analysis, Investigation, Writing – Review & Editing, Funding acquisition. Margaret Q. To: Conceptualization, Methodology, Formal analysis, Investigation, Writing – Review & Editing, Funding acquisition. Patrick S. Sullivan: Supervision, Writing – Review & Editing. Carol M. Worthman: Supervision, Writing – Review & Editing. Le Minh Giang: Project Coordination, Supervision, Writing – Review & Editing. Tanja Jovanovic: Supervision, Writing – Review & Editing.

References

  1. Andrade LH, Alonso J, Mneimneh Z, Wells JE, Al-Hamzawi A, Borges G, et al. (2014). Barriers to mental health treatment: results from the WHO World Mental Health surveys. Psychological Medicine, 44(6), 1303–1317. 10.1017/S0033291713001943 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Arseniou S, Arvaniti A, & Samakouri M (2014). HIV infection and depression. Psychiatry and Clinical Neurosciences, 68(2), 96–109. 10.1111/pcn.12097 [DOI] [PubMed] [Google Scholar]
  3. Biello KB, Colby D, Closson E, & Mimiaga MJ (2013). The Syndemic Condition of Psychosocial Problems and HIV Risk Among Male Sex Workers in Ho Chi Minh City, Vietnam. AIDS and Behavior, 18(7), 1264–1271. 10.1007/s10461-013-0632-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Chaudhury S, Bakhla A, & Saini R (2016). Prevalence, impact, and management of depression and anxiety in patients with HIV: a review. Neurobehavioral HIV Medicine, 15–17. 10.2147/NBHIV.S68956 [DOI]
  5. Chibanda D, Cowan FM, Healy JL, Abas M, & Lund C (2015). Psychological interventions for Common Mental Disorders for People Living With HIV in Low-and Middle-Income Countries: systematic review. Tropical Medicine and International Health, 20(7), 830–839. 10.1111/tmi.12500 [DOI] [PubMed] [Google Scholar]
  6. Chuah FLH, Haldane VE, Cervero-Liceras F, Ong SE, Sigfrid LA, Murphy G, et al. (2017). Interventions and approaches to integrating HIV and mental health services: a systematic review. Health Policy and Planning, 32(suppl_4), iv27–iv47. 10.1093/heapol/czw169 [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Collins PY, Holman AR, Freeman MC, & Patel V (2006). What is the relevance of mental health to HIV/AIDS care and treatment programs in developing countries? A systematic review. Aids, 20(12), 1571–1582. 10.1097/01.aids.0000238402.70379.d4 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Collins PY, Sweetland AC, & Wagenaar BH (2020). Ending HIV and Tuberculosis—What Has Mental Health Got to Do with It? JAMA Health Forum, 1(7), e200852–e200852. 10.1001/jamahealthforum.2020.0852 [DOI] [PubMed] [Google Scholar]
  9. Creswell JW (1998) Qualitative inquiry and research design: Choosing among five traditions London: Sage. [Google Scholar]
  10. Dang H-M, Weiss B, Lam T, & Ho H (2018). Mental health literacy and intervention program adaptation in the internationalization of school psychology for Vietnam. Psychology in the Schools, 55(8), 941–954. 10.1002/pits.22156 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Esposito CA, Steel Z, Gioi TM, Huyen TTN, & Tarantola D (2009). The prevalence of depression among men living with HIV infection in Vietnam, 99 Suppl 2(S2), S439–44. 10.2105/AJPH.2008.155168 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Freeman M, Patel V, Collins PY, & Bertolote J (2005). Integrating mental health in global initiatives for HIV/AIDS. The British Journal of Psychiatry, 187(1), 1–3. 10.1192/bjp.187.1.1 [DOI] [PubMed] [Google Scholar]
  13. Fulton BD, Scheffler RM, Sparkes SP, Auh EY, Vujicic M, & Soucat A (2011). Health workforce skill mix and task shifting in low-income countries: a review of recent evidence. Human Resources for Health, 9(1), 1. 10.1186/1478-4491-9-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Gammeltoft TM (2008). Figures of transversality: State power and prenatal screening in contemporary Vietnam. American Ethnologist, 35(4), 570–587. 10.1111/j.1548-1425.2008.00099.x [DOI] [Google Scholar]
  15. Giang KB, Dzung TV, Kullgren G, & Allebeck P (2010). Prevalence of mental distress and use of health services in a rural district in Vietnam. Global Health Action, 3. 10.3402/gha.v3i0.2025 [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Goldsamt LA, Clatts MC, Giang LM, & Yu G (2014). Prevalence and behavioral correlates of depression and anxiety among male sex workers in Vietnam. International Journal of Sexual Health, 27(2), 145–155. 10.1080/19317611.2014.947055 [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Green KE, Vu BN, Phan HT, Tran MH, Ngo HV, Vo SH, et al. (2018). From conventional to disruptive: upturning the HIV testing status quo among men who have sex with men in Vietnam. Journal of the International AIDS Society, 21 Suppl 5, e25127. 10.1002/jia2.25127 [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Hampshire K, Porter G, Mariwah S, Munthali A, Robson E, Owusu SA, et al. (2017). Who bears the cost of “informal mhealth?” Health-workers’ mobile phone practices and associated political-moral economies of care in Ghana and Malawi. Health Policy and Planning, 32(1), 34–42. 10.1093/heapol/czw095 [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Heywood W, & Lyons A (2016). HIV and elevated mental health problems: diagnostic, treatment, and risk patterns for symptoms of depression, anxiety, and stress in a national community-based cohort of gay men living with hiv. AIDS and Behavior, {20}({8}), {1632–1645}. { 10.1007/s10461-016-1324-y} [DOI] [PubMed] [Google Scholar]
  20. Horton P (2014). “I thought I was the only one”: The misrecognition of LGBT youth in contemporary Vietnam. Culture, Health & Sexuality, 16(8), 960–973. 10.1080/13691058.2014.924556 [DOI] [PubMed] [Google Scholar]
  21. Joshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, & Patel AA (2014). Task Shifting for non-communicable disease management in low-and middle-income countries – A systematic review. PLoS ONE, 9(8), e103754–9. 10.1371/journal.pone.0103754 [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Kaaya S, Eustache E, Lapidos-Salaiz I, Musisi S, Psaros C, & Wissow L (2013). Grand Challenges: Improving HIV treatment outcomes by integrating interventions for co-morbid mental illness. PLoS Medicine, 10(5), e1001447–6. 10.1371/journal.pmed.1001447 [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Kakuma R, Minas H, van Ginneken N, Dal Poz MR, Desiraju K, Morris JE, et al. (2011). Human resources for mental health care: current situation and strategies for action. Lancet, 378(9803), 1654–1663. 10.1016/S0140-6736(11)61093-3 [DOI] [PubMed] [Google Scholar]
  24. Kamimura A, Trinh HN, Johansen M, Hurley J, Pye M, Sin K, & Nguyen H (2018). Perceptions of mental health and mental health services among college students in Vietnam and the United States. Asian Journal of Psychiatry, 37, 15–19. 10.1016/j.ajp.2018.07.012 [DOI] [PubMed] [Google Scholar]
  25. Kohrt BA, & Hruschka DJ (2010). Nepali concepts of psychological trauma: the role of idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and preventing stigma. Culture, Medicine, and Psychiatry, 34(2), 322–352. 10.1007/s11013-010-9170-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Kottai SR, & Ranganathan S (2020). Task-shifting in community mental health in Kerala: Tensions and ruptures. Medical Anthropology, 00(00), 1–15. 10.1080/01459740.2020.1722122 [DOI] [PubMed] [Google Scholar]
  27. Laqua C, Hahn E, Böge K, Martensen LK, Nguyen TD, Schomerus G, et al. (2018). Public attitude towards restrictions on persons with mental illness in greater Hanoi area, Vietnam. International Journal of Social Psychiatry, 64(4), 335–343. 10.1177/0020764018763685 [DOI] [PubMed] [Google Scholar]
  28. Lora A, Kohn R, Levav I, McBain R, Morris J, & Saxena S (2011). Service availability and utilization and treatment gap for schizophrenic disorders: A survey in 50 low-and middle-income countries. Bulletin of the World Health Organization, 90(1), 47–54B. 10.2471/BLT.11.089284 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Mijovic H, McKnight J, & English M (2016). What does the literature tell us about health workers’ experiences of task‐ shifting projects in sub‐ Saharan Africa? A systematic, qualitative review. Journal of Clinical Nursing, 25(15–16), 2083–2100. 10.1111/jocn.13349 [DOI] [PMC free article] [PubMed] [Google Scholar]
  30. Nanni MG, Caruso R, Mitchell AJ, Meggiolaro E, & Grassi L (2014). Depression in HIV infected patients: A review. Current Psychiatry Reports, 17(1), e442.2006–11. 10.1007/s11920-014-0530-4 [DOI] [PubMed] [Google Scholar]
  31. Ng CH, Than PT, La CD, Van Than Q, & Van Dieu C (2011). The National Community Mental Health Care Project in Vietnam: A review for future guidance. Australasian Psychiatry, 19(2), 143–150. 10.3109/10398562.2011.563308 [DOI] [PubMed] [Google Scholar]
  32. Nguyen DT, Wright EP, Pham TT, & Bunders J (2020). Role of school health officers in mental health care for secondary school students in Can Tho City, Vietnam. School Mental Health, 1–11. 10.1007/s12310-020-09386-7 [DOI] [PMC free article] [PubMed]
  33. Nguyen HT, Nguyen AQ, Nguyen PTK, Duong AT, & Nguyen HT (2020b). External funding reduction of HIV/AIDS programme: Exploring options for financial sustainability. International Journal of Healthcare Management, 0(0), 1–9. 10.1080/20479700.2020.1797333 [DOI] [Google Scholar]
  34. Nguyen T, Tran T, Green S, Hsueh A, Tran T, Tran H, & Fisher J (2019). Delays to diagnosis among people with severe mental illness in rural Vietnam, a population-based cross-sectional survey, 1–11. 10.1186/s12888-019-2367-1 [DOI] [PMC free article] [PubMed]
  35. Niemi M, Thanh HT, Tuan T, & Falkenberg T (2010). Mental health priorities in Vietnam: A mixed-methods analysis. BMC Health Services Research, 10(1), 1061–10. 10.1186/1472-6963-10-257 [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Pallas CL, & Nguyen L (2018). Donor withdrawal and local civil society organizations: An analysis of the HIV/AIDS sector in Vietnam. Development Policy Review
  37. Patel V, Maj M, Flisher AJ, De Silva MJ, Koschorke M, Prince M, WPA Zonal and Member Society Representatives. (2010). Reducing the treatment gap for mental disorders: a WPA survey. World Psychiatry, 9(3), 169–176. 10.1002/j.2051-5545.2010.tb00305.x [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Paul H, & Helle R (2020). Reshaping boundaries: Family politics and GLBTQ resistance in urban Vietnam. Journal of GLBT Family Studies, 15(3), 290–305. 10.1080/1550428X.2018.1518739 [DOI] [Google Scholar]
  39. Peltzer K, Pengpid S, Puckpinyo A, Yi S, & Le VA (2016). The utilization of traditional, complementary and alternative medicine for non-communicable diseases and mental disorders in health care patients in Cambodia, Thailand and Vietnam. BMC Complementary and Alternative Medicine, 1–11. 10.1186/s12906-016-1078-0 [DOI] [PMC free article] [PubMed]
  40. Rehm J, & Shield KD (2019). Global burden of disease and the impact of mental and addictive disorders, 1–7. 10.1007/s11920-019-0997-0 [DOI] [PubMed]
  41. Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, & Mellins CA (2019). Mental health and HIV/AIDS. Aids, 33(9), 1411–1420. 10.1097/QAD.0000000000002227 [DOI] [PMC free article] [PubMed] [Google Scholar]
  42. Shidhaye R, Baron E, Murhar V, Rathod S, Khan A, Singh A, et al. (2019). Community, facility and individual level impact of integrating mental health screening and treatment into the primary healthcare system in Sehore district, Madhya Pradesh, India. BMJ Global Health, 4(3), e001344–18. 10.1136/bmjgh-2018-001344 [DOI] [PMC free article] [PubMed] [Google Scholar]
  43. Simioni S, Cavassini M, Annoni J-M, Rimbault Abraham A, Bourquin I, Schiffer V, et al. (2010). Cognitive dysfunction in HIV patients despite long-standing suppression of viremia. Aids, 24(9), 1243–1250. 10.1097/QAD.0b013e3283354a7b [DOI] [PubMed] [Google Scholar]
  44. Ta TMT, Zieger A, Schomerus G, Cao TD, Dettling M, Do XT, et al. (2016). Influence of urbanity on perception of mental illness stigma: a population-based study in urban and rural Hanoi, Vietnam. International Journal of Social Psychiatry, 62(8), 685–695. 10.1177/0020764016670430 [DOI] [PubMed] [Google Scholar]
  45. Thai QCN, & Nguyen TH (2018). Mental health literacy: knowledge of depression among undergraduate students in Hanoi, Vietnam. International Journal of Mental Health Systems, 1–8. 10.1186/s13033-018-0195-1 [DOI] [PMC free article] [PubMed]
  46. Thai TT, Jones MK, Harris LM, & Heard RC (2016). Prevalence and correlates of symptoms of mental disorders in Vietnamese HIV positive patients. Journal of HIV/AIDS & Social Services, 121(4), 1–17. 10.1080/15381501.2015.1107800 [DOI] [Google Scholar]
  47. Thai TT, Jones MK, Harris LM, Heard RC, Hills NK, & Lindan CP (2017). Symptoms of depression in people living with HIV in Ho Chi Minh City, Vietnam: Prevalence and associated factors. AIDS and Behavior, 22(S1), 76–84. 10.1007/s10461-017-1946-8 [DOI] [PMC free article] [PubMed] [Google Scholar]
  48. Tran TC, Pham TD, Nguyen TD, Olson L, & Larsson M (2020). Fundraising capacity of HIV/AIDS community-based organizations in 3 years (2017–2019) in Ho Chi Minh City, Vietnam. World Journal of AIDS, 10, 186–194. 10.4236/wja.2020.103016 [DOI] [Google Scholar]
  49. Udedi M, Stockton MA, Kulisewa K, Hosseinipour MC, Gaynes BN, Mphonda SM, et al. (2018). Integrating depression management into HIV primary care in central Malawi: The implementation of a pilot capacity building program, 1–12. 10.1186/s12913-018-3388-z [DOI] [PMC free article] [PubMed]
  50. USAID. (2018). Overview of HIV Viet Nam Retrieved March 1, 2020, from https://www.unaids.org/en/regionscountries/countries/vietnam
  51. Uthman OA, Magidson JF, Safren SA, & Nachega JB (2014). Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: A systematic review and meta-analysis. Current HIV/AIDS Reports, 11(3), 291–307. 10.1007/s11904-014-0220-1 [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. van der Ham L, Wright P, Van TV, Doan VDK, & Broerse JEW (2011). Perceptions of mental health and help-seeking behavior in an urban community in Vietnam: An explorative study. Community Mental Health Journal, 47(5), 574–582. 10.1007/s10597-011-9393-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Vu BN, Green KE, Thi Thu Phan H, Hung Tran M, Van Ngo H, Hai Vo S, et al. (2018). Lay provider HIV testing: A promising strategy to reach the undiagnosed key populations in Vietnam. PLoS ONE, 13(12), e0210063–16. 10.1371/journal.pone.0210063 [DOI] [PMC free article] [PubMed] [Google Scholar]
  54. Vuong DA, Van Ginneken E, Morris J, Ha ST, & Busse R (2011). Mental health in Vietnam: Burden of disease and availability of services. Asian Journal of Psychiatry, 4(1), 65–70. 10.1016/j.ajp.2011.01.005 [DOI] [PubMed] [Google Scholar]
  55. Walkup J, Blank MB, Gonzalez JS, Safren S, Schwartz R, Brown L, et al. (2008). The impact of mental health and substance abuse factors on HIV prevention and treatment. JAIDS Journal of Acquired Immune Deficiency Syndromes, 47 Suppl 1(Supplement 1), S15–9. 10.1097/QAI.0b013e3181605b26 [DOI] [PubMed] [Google Scholar]
  56. Weiss B, Dang H-M, Ngo V, Pollack A, Sang D, Lam TT, et al. (2011). Development of clinical psychology and mental health resources in Vietnam. Psychological Studies, 56(2), 185–191. 10.1007/s12646-011-0078-x [DOI] [PMC free article] [PubMed] [Google Scholar]
  57. Wright E, Brew B, Arayawichanont A, Robertson K, Samintharapanya K, Kongsaengdao S, et al. (2008). Neurologic disorders are prevalent in HIV-positive outpatients in the Asia- Pacific region. Neurology, 71(1), 50–56. 10.1212/01.wnl.0000316390.17248.65 [DOI] [PubMed] [Google Scholar]
  58. Young RM, & Meyer IH (2005). The trouble with “MSM” and “WSW”: erasure of the sexual-minority person in public health discourse. American Journal of Public Health, 95(7), 1144–1149. 10.2105/AJPH.2004.046714 [DOI] [PMC free article] [PubMed] [Google Scholar]
  59. Woelbert E, White R, Lundell-Smith K, Grant J, & Kemmer D (2020). The Inequities of Mental Health Research (IAMHRF) (Version 2). Digital Science 10.6084/m9.figshare.13055897.v2 [DOI]

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