Mental health (MH) disorders disproportionately impact people living with HIV, affecting their adherence to antiretroviral therapy (ART), care-seeking, and health outcomes.

At ART clinics in Malawi, lay cadre workers were trained to provide MH screening for depression and harmful alcohol use for clients who were newly diagnosed with HIV, had high viral loads, or were returning to care after treatment interruption and to refer clients to specialized care for MH disorders.

The vast majority of individuals screened and found with depression symptoms and/or harmful alcohol use could be managed at the ART clinics, with few referrals for more severe cases required.

Where adequate human and financial resources are available, MH screening should be scaled up to all ART clinics.

National stakeholders should strengthen the infrastructure at health facilities needed to provide quality, integrated care for MH with sufficient privacy.

Further implementation research is needed to measure the impact of integrated MH screening on ART and MH outcomes over time and to determine cost-effectiveness.

Mental health (MH) disorders are highly prevalent among people living with HIV and can have a negative impact on antiretroviral therapy (ART) outcomes. Malawi’s Ministry of Health introduced MH screening in national HIV management guidelines in 2022. We describe early experience with integrated MH screening at ART clinics that have scarce human resources and limited capacity of specialist MH units. ART staff in 15 facilities were trained to use the Patient Health Questionnaire-9 (depression) and the Alcohol Use Disorders Identification Test (harmful alcohol use) screening instruments, MH registers were developed for tracking screening results and referrals, and existing MH referral units were engaged. Based on screening results, ART clients received counseling by lay cadre staff (for mild symptoms) or intensive counseling by trained psychosocial counselors and referrals to specialist MH units (for moderate to severe symptoms). From October 2022 through July 2023, 9,826 ART clients were screened from the following priority groups: returning to care after an interruption in treatment (50%), newly diagnosed (38%), and viral load ≥1,000 copies/mL (12%). Of those screened, 59% were female and 14% were aged 12–19 years. Screening coverage was 85% (9,826/11,553) among the 3 priority groups. All of the individuals who screened positive for moderate/severe depression (1.1%; n=106) or high risk for harmful alcohol use (2.3%; n=227) were referred to specialist MH units. In conclusion, thorough preparation led to high MH screening coverage among ART priority groups, and the number of referrals to specialist MH units was low. MH screening was feasible at Malawi ART clinics. Next steps include studying the clinical impact of integrated MH screening on MH outcomes and ART outcomes (retention in care and viral suppression) and scaling up integrated MH screening to all ART clinics.

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