By Jamie Hansen, Global Health Communications Manager

When an adolescent girl dies in Kenya, there’s a one-in-four chance that HIV was the cause — despite the availability of life-saving treatments. Poor mental health and interpersonal violence are two important barriers that often prevent these girls from receiving and/or adhering to the needed antiretroviral therapy treatment, and now Stanford and Kenyan researchers are collaborating to explore community-based solutions to this devastating problem.

Around the world, violence, poor mental health, and HIV present interconnected threats to youth ages 15-24: More than half of teenagers and young women who experience violence develop mental health conditions, and those who experience multiple episodes of violence are 50% more likely to become infected with HIV. The problem is particularly acute for girls and young women in western Kenya, where girls aged 10-19 bear much of the burden of HIV. They are nearly twice as likely to be living with HIV as adolescent boys — while also being more likely to experience violence.

In Kenya, the Ministry of Health has prioritized addressing high rates of youth HIV/AIDS and helping adolescents adhere better to their treatments —  but has lacked the data necessary to understand the reasons for those missed treatments. Recently, Stanford Clinical Associate Professor of Pediatrics and Global Health Faculty Fellow Clea Sarnquist, DrPH, MPH, Associate Professor of Epidemiology and Population Health Michael Baiocchi, and Doctoral Student in Epidemiology Jonathan Altamirano, PhD(c) teamed up with the Kenyan Medical Research Institute to address this urgent gap in research and care.

In research conducted around Kisumu, Kenya and published last year, they found that the odds of teenage girls and young women missing their HIV treatments more than doubled for those who reported suffering emotional violence, compared with those who did not. They also found that nearly 40 percent of girls with HIV reported experiencing emotional violence. 

“That’s insanely high,” said Sarnquist, who has studied the interplay between gender-based violence and HIV in Sub-Saharan Africa for more than 10 years. “On top of that, we found that depression was quite high, and associated with not taking ART medication.”

Researchers believe the issue is particularly important post-COVID-19, which worsened mental health conditions for youth across the world, particularly young women. They hope that other areas dealing with high rates of HIV and youth mental health challenges can adapt the low-cost, community-based approaches they are exploring.

“A lot of the mental health challenges we’re describing with young girls were already there, but the pandemic exacerbated them to a level that is truly horrifying,” said Altamirano.

Yet while supporting young women’s mental health emerged as a clear priority of the community from their research, the need is greater than the capacity. There are only about 100 psychiatrists in all of Kenya, and it is difficult for Kenya to retain those they train.

Qualitative interviews with the adolescent girls and young women uncovered one approach to be the most welcome, approachable, and feasible: Friendship Bench. This program, developed in Zimbabwe, is a low-cost psychological intervention that empowers community members to support the mental health of young people. A clinical team trains community health workers, often elders such as local grandmothers, to provide problem-based  therapy to young people suffering from anxiety or depression. The trained workers then sit with their clients outdoors, under the trees, on wooden park benches, creating safe spaces and a sense of belonging in communities. This program has extensive evidence of improving mental health among a range of populations, including those living with HIV. 

Sarnquist, Altamirano, and Baiocchi have now received funding from Stanford’s Maternal and Child Health Research Institute to pilot and adapt a version of this program to best serve young women living with HIV in western Kenya. The researchers also aim to create a shorter version of the intervention that is customized to adolescents living with HIV. Doing so, they hope, will streamline the intervention to achieve the same results with fewer resources, enabling them to reach more young people resource-constrained settings. For the current grant, they’ll develop and test it using a proven improvement science framework for adapting HIV interventions, which includes many steps designed to gather input from the girls living with HIV along with local experts.

“We’re trying to respond to this dire need with the understanding that we’re not going to be able to train and retain a bunch of new mental health professionals,” said Sarnqiust.

Altamirano added that this research is critical to serve a vulnerable and under-researched population, adolescent girls. “The more that we learn about this incredibly vulnerable population, we learn that these girls often don’t have access to medical or mental health resources but are nonetheless bearing the brunt of the incidence of HIV and poor mental health,” he said. “In listening to the community and our partners in Kenya, there’s a clear, pressing need to particularly work in this adolescent and young adult population.” 

Altamirano plans to focus on such research as he pursues his PhD with support from a Stanford DARE fellowship. He’s received funding from the King Center on Global Development to conduct another study following the same cohort of young women from the previously-published study two years later, in order to better understand the relationship between gender-based violence, mental health, and adherence to ART treatments. 

Sarnquist hopes to see more funding opportunities that support adapting and testing interventions such as Friendship Bench. “One of the challenges of behavioral interventions is that structural factors change over time, resulting in the need for ongoing refinement and evaluation,” she said. “We need more iterative research and implementation approaches to meet these growing and evolving challenges.”

Acknowledgments

Dr. Sarnquist is also a clinical associate professor (by courtesy) in the Stanford Department of Epidemiology and Population Health. This research was supported by a Global Health Seed Grant funded by the Stanford Center for Innovation in Global Health and Stanford Maternal & Child Health Research Institute.