People living with HIV experience psychosocial needs that often are not addressed. We designed an innovative low-resource model of phone-based psychosocial counseling (P-PSC). We describe cohort characteristics, acceptability, feasibility and utilization of P-PSC at health facilities supported by Baylor Foundation Malawi. Staff were virtually oriented at 120 sites concurrently. From facility-based phones, people with new HIV diagnosis, high viral load, treatment interruption or mental health concerns were referred without identifiable personal information to 13 psychosocial counselors via a WhatsApp group. Routine program data were retrospectively analyzed using univariate approaches and regressions with interrupted time series analyses. Clients utilizing P-PSC were 63% female, 25% youth (10-24 y) and 9% children (<10 y). They were referred from all 120 supported health facilities. Main referral reasons included new HIV diagnosis (32%), ART adherence support (32%) and treatment interruption (21%). Counseling was completed for 99% of referrals. Counseling sessions per month per psychosocial counselor increased from 77 before P-PSC to 216 in month 1 (95% CI = 82, 350, p = 0.003). Total encounters increased significantly to 31,642 in year 1 from ~6,000 during the 12 prior months, an over fivefold increase. P-PSC implementation at 120 remote facilities was acceptable and feasible with immediate, increased utilization despite few psychosocial counselors in Malawi.
Impact statementPeople living with HIV (PLHIV) frequently need psychosocial health services, but access remains suboptimal. The shortage of skilled mental healthcare providers is particularly acute in sub-Saharan Africa, home to most PLHIV. In Malawi, lay community health workers provide most first-line facility-based counseling for PLHIV and refer those clients who have needs that exceed their counseling capacity to psychosocial counselors, a cadre more extensively trained in and dedicated to counseling. The Baylor Foundation Malawi's Tingathe program has been supporting psychosocial counselors at 10 high-volume facilities to provide in-person counseling since 2017; and in 2020, to continue service delivery amidst COVID-19 mitigation strategies, phone-based psychosocial counseling (P-PSC) services were started. We describe this P-PSC service's implementation, feasibility and acceptability in Malawi. A pool of 13 psychosocial counselors provided phone-based counseling to clients from 120 health facilities. Our results show that P-PSC was acceptable and feasible in Malawi. P-PSC expanded access to psychosocial counselors twelvefold, from 10 to all 120 supported health facilities, and over 30,000 counseling sessions were conducted in the first year alone. P-PSC was delivered simultaneously to many geographically dispersed facilities with a core team of trained providers. P-PSC has shown great promise as an efficient and scalable model of counseling by trained psychosocial counselors in limited resource settings with shortages of skilled mental health workers.
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