Rwanda's Innovative Effort Tackles Comorbid HIV, Mental Illness

Rwanda, a small African country with 9 million people, is not only feeling the psychiatric aftereffects of a genocide that occurred 17 years ago, but is also struggling with an epidemic of HIV infections. During the past five years, two American psychiatrists have been helping their Rwandan colleagues deal with the double burden of HIV infections and serious mental illness.

One is Pamela Collins, M.D., an associate clinical professor of epidemiology and psychiatry at Columbia University and director of the Office for Research on Disparities and Global Mental Health at the National Institute of Mental Health. The other is Francine Cournos, M.D., a professor of clinical psychiatry at Columbia University and an HIV expert.

In 2007, Collins first visited Rwanda while working with ICAP, an AIDS initiative affiliated with Columbia University's Mailman School of Public Health and funded through the President's Emergency Plan for AIDS Relief, which started under the George W. Bush administration. ("ICAP used to stand for something, but doesn't anymore," Cournos explained.)

During this visit, Collins delivered a presentation on HIV and mental health to ICAP-Rwanda staff and other leaders of Rwanda's small mental health workforce. In the ensuing discussion, she learned that HIV care providers were interested in learning more about mental health, and mental health care providers wanted more information on HIV.

The coordinator of mental health for the Rwandan Ministry of Health, Yvonne Kayiteshonga, and Brother Charles Nkubili, director of Rwanda's only neuropsychiatric hospital, Ndera, were especially interested in the topic. Moreover, Ruben Sahabo, M.D., head of ICAP-Rwanda, was enthusiastic about expanding HIV care in Rwanda, Collins reported. "So the stage was set for a collaboration between these various people and myself," she told Psychiatric News. "We wanted to provide greater access to combined mental health and HIV services for Rwandans with mental disorders and greater access to mental health services for Rwandans with HIV."

Collins started by documenting HIV care and prevention needs in Rwandan mental health facilities and assessing the need for mental health services and training among Rwandan HIV care providers. Subsequently, ICAP-Rwanda, the Rwandan Ministry of Health, and Ndera Neuropsychiatric Hospital worked together to establish HIV services at Ndera.

In January 2009, not long after the first patients at Ndera began receiving HIV testing, Collins and Ndera colleague Alfred Ngirababyeyi, M.D., led a two-day workshop for mental health providers and began to lay out a plan with Rwandan Ministry of Health partners on referral, follow-up, and testing guidelines for HIV-positive psychiatric patients. Later that year, Cournos joined in this effort.

Since 2009, more than 1,000 Ndera patients have been tested for HIV, and those found to be positive—about 10 percent—receive treatment for the virus in combination with the mental health care that they are receiving in the hospital.

"Let's say you're entering Ndera as a mentally ill patient," Cournos explained in an interview. "You will be offered HIV testing, and if you test positive, you will be enrolled in care for your HIV infection along with treatment for your mental illness. After you leave the hospital, you can continue to receive HIV care as well as psychiatric care from the hospital as long as you live close enough to it to go there."

Furthermore, in 2010, Collins and Cournos helped support the efforts of their Rwandan colleagues to include Rwanda's 49 district hospitals in the integration of HIV-related mental health services. The district hospitals are essentially Rwanda's second line of health care after primary care facilities.

And since December 2010, Cournos has been working on developing ways in which HIV care nurses and mental health nurses in the district hospitals can provide integrated mental health and HIV care.

For example, Cournos was involved in the creation of mental health training for the HIV nurses that included an introduction to common mental disorders, specifically within the context of HIV infection. Cournos also recommended two instruments that the HIV nurses in the district hospitals could use for screening patients for mental disorders, and she is in the process of having the screening instrument questions translated into the Rwandan language.

"I am still working on modifying some tools for them," Cournos said. "But now it's more in the hands of the Rwandan Ministry of Health. It is one of these situations where maybe a lot will come of it, but what is feasible remains unclear."

"The long-term effect of a policy-and-service intervention—that's essentially what this is—depends on so many factors," Collins explained. "What we have focused on is the potential to provide greater access to combined mental health and HIV services for people with mental disorders and greater access to mental health services for people with HIV. In that sense, being able to reduce the burden of both kinds of illness would have a long-term positive effect. But the biggest challenge is the lack of mental health human resources in Rwanda. There simply are not many providers (nurses, doctors, or psychologists) with mental health expertise. The numbers are increasing, but there is a great need for more."

But whether the intervention helps to a greater or lesser extent, Collins stressed, "it is ultimately led by Rwandans. Fran Cournos and I have simply served as catalysts and technical experts. There is nothing that we have done alone during this initiative. Indeed, at times, we have had to learn from our Rwandan colleagues."