Background Perinatal depression (PND) can interfere with HIV care engagement and outcomes. We examined experiences of PND among women living with HIV (WLWH) in Malawi. Methods We screened 73 WLWH presenting for perinatal care in Lilongwe, Malawi using the Edinburgh Postnatal Depression Scale (EPDS). We conducted qualitative interviews with 24 women experiencing PND and analyzed data using inductive and deductive coding and narrative analysis. Results Women experienced a double burden of physical and mental illness, expressed as pain in one's heart. Receiving an HIV diagnosis unexpectedly during antenatal care was a key contributor to developing PND. This development was influenced by stigmatization and social support. Conclusions These findings highlight the need to recognize the mental health implications of routine screening for HIV and to routinely screen and treat PND among WLWH. Culturally appropriate mental health interventions are needed in settings with a high HIV burden.

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20 21 Background: Perinatal depression (PND) can interfere with HIV care engagement and outcomes. 22 We examined experiences of PND among women living with HIV (WLWH) in Malawi. 23 24 Methods: We screened 73 WLWH presenting for perinatal care in Lilongwe, Malawi using the 25 Edinburgh Postnatal Depression Scale (EPDS). We conducted interviews with 24 women 26 experiencing PND and analyzed data using inductive and deductive coding and narrative 27 analysis. 28 29 Results: Women experienced a double burden of physical and mental illness, expressed as pain 30 in one's heart. Receiving an HIV diagnosis unexpectedly during antenatal care was a key 31 contributor to developing PND. This development was influenced by stigmatization and social 32 support. 33 34 Conclusions: These findings highlight the need to recognize the mental health implications of 35 routine screening for HIV and to routinely screen and treat PND among WLWH. Culturally 36 appropriate mental health interventions are needed in settings with a high HIV burden. 37 38 Introduction 39The scale-up of antiretroviral therapy to all pregnant and breastfeeding women living 40 with HIV, known as Option B+, has the potential to dramatically improve maternal health and 41 end mother-to-child HIV transmission (MTCT) (1). In Malawi, all pregnant women diagnosed 42 with HIV in antenatal care (ANC) begin lifelong antiretroviral therapy (ART) under Option B+ 43 (2). However, women who initiate ART during pregnancy under Option B+ are one-fifth as 44 likely to return to HIV care after their initial visit compared to non-pregnant women initiating 45 ART in Malawi (3). Maternal mental health is likely an important factor in undermining the 46 delivery of Option B+ by affecting initiation of and retention in HIV care, with implications for 47 ongoing risk of MTCT and negative effects on women's quality of life and psychological well-48 being (4). 49Globally, adults living with HIV are at an increased risk of depression, with the 50 association being stronger among patients who are newly diagnosed and women (5). A 51 systematic review conducted in high-, middle-, and low-income countries found that pregnant 52 and postpartum women living with HIV are at particularly high risk for perinatal depression 53 (PND) due to multiple bio-psychosocial risk factors (4). These risk factors include increased 54 stress, HIV-related stigma, a lack of social support, concerns about disclosing their HIV status, 55 and concerns about their infant's health and HIV status (4). 56Through Option B+, more women are becoming aware of their HIV status and initiating 57 ART during the perinatal period. Simultaneously, many are experiencing PND. PND is known to 58 affect 13.1% of women in low and middle-income countries, with as many as 19.2% of women 59 having a depressive episode within the first three months postpartum (6,7). Among women living 60 with HIV in Sub-Saharan Africa, a meta-analysis found a pooled prevalence for PND of 42.5% 61 for prenatal women and 30.7% for postpartum women, indic...

The SARS-CoV-2 pandemic led to the rapid transition of many research studies from in-person to telephone follow-up globally. For mental health research in low-income settings, tele-follow-up raises unique safety concerns due to the potential of identifying suicide risk in participants who cannot be immediately referred to in-person care. We developed and iteratively adapted a telephone-delivered protocol designed to follow a positive suicide risk assessment (SRA) screening. We describe the development and implementation of this SRA protocol during follow-up of a cohort of adults with depression in Malawi enrolled in the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP) randomized control trial during the COVID-19 era. We assess protocol feasibility and performance, describe challenges and lessons learned during protocol development, and discuss how this protocol may function as a model for use in other settings. Transition from in-person to telephone SRAs was feasible and identified participants with suicidal ideation (SI). Follow-up protocol monitoring indicated a 100% resolution rate of SI in cases following the SRA during this period, indicating that this was an effective strategy for monitoring SI virtually. Over 2% of participants monitored by phone screened positive for SI in the first six months of protocol implementation. Most were passive risk (73%). There were no suicides or suicide attempts during the study period. Barriers to implementation included use of a contact person for participants without personal phones, intermittent network problems, and pre-paid phone plans delaying follow-up. Delays in follow-up due to challenges with reaching contact persons, intermittent network problems, and pre-paid phone plans should be considered in future adaptations. Future directions include validation studies for use of this protocol in its existing context. This protocol was successful at identifying suicide risk levels and providing research assistants and participants with structured follow-up and referral plans. The protocol can serve as a model for virtual SRA development and is currently being adapted for use in other contexts.

Background Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics. Methods We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics. Results Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting. Conclusion Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.