- People with HIV have a big chance of struggling with mental health problems such as depression or anxiety — which could stop them from taking their HIV pills as they should.
- Getting treatment for mental health challenges can help, but for that to work, medication must be accessible. At the moment, though, only doctors can prescribe psychiatric medicines — and most government clinics don’t have full-time doctors.
- South Africa’s HIV plan has a solution: to allow nurses to prescribe psychiatric drugs. But how would that work?
- In this Health Beat interview, Mia Malan asks Francois Venter, who’s lived through HIV with his patients for the past 20 years, whether getting nurses to hand out mental health medication would be as beneficial as allowing them to prescribe HIV treatment (this happened in 2010).
By 2028, trained nurses in South Africa should be able to prescribe psychiatric medicines — if lawmakers move fast enough. This will make antidepressants and drugs to deal with anxiety easier to get, especially for people with HIV, who are about five times more likely than those without the virus to have depression, and eight times more likely to experience anxiety.
Currently only doctors can prescribe mental health medication, but the country’s national, five-year HIV plan, which ends in 2028, aims to change this, as treating mental health challenges results in people with chronic conditions such as HIV finding it easier to stay on treatment.
Once the health minister publishes draft regulations to say who may give out what kind of drugs, it “could be a matter of months” for the new rules to come into effect, says Andy Gray, a senior lecturer in pharmacology at the University of KwaZulu-Natal and a member of the committee who advises the government on which medicines to buy.
Watch the full interview
The health department has not yet announced when it will start the process for changing the law, but the matter is urgent and relatively high on the department’s agenda, experts say, because adjusted legislation will help to slow down the spread of HIV.
How?
Research has shown that there’s a big chance for someone with HIV to struggle with a psychological problem such as depression or anxiety too or to think about suicide.
Mental health challenges such as depression and anxiety are associated with people with HIV taking their medicine less regularly — which means they could stay infectious. Taking HIV drugs every day stops the virus from multiplying in your body and so lets the level of the virus drop so much that it’s virtually impossible to transmit the infection through sex.
But South Africa’s government health system — which most HIV-positive people in the country use to get their treatment — doesn’t have nearly enough doctors to staff clinics full-time. (There are about eight doctors for every 10 000 people in South Africa, while the number sits at about 21 per 10 000 people in other upper middle-income countries.) Instead, nurses run such clinics, with doctors only doing shifts once or twice a week.
Getting nurses to diagnose mental health conditions and to prescribe treatment, will mean that patients won’t have to return for doctors’ appointments to get treated.
This will not be the first time such task shifting is written into the country’s laws to help us get the spread of HIV under control.
When free antiretrovirals (ARVs) were introduced to South Africa’s public health system in 2004, only doctors were allowed to prescribe these HIV pills. Since 2010, however, nurses have been able to do this too — which is part of the reason why about 6.1-million people with HIV are on treatment today (this is about 77% of people who know they have HIV).
And ARVs have become even more accessible: in August, trained pharmacists were given permission to prescribe them too.
Most mental health medicines are schedule 5 drugs, which is why only doctors can prescribe them. At the moment nurses can hand out drugs only up to schedule 4, says Gray, so changing this rule will be the first step in getting the process for better access to mental health treatment started.
A change in law won’t be enough, though. Nurses will have to get special training for dispensing psychiatric medicines, similar to what nurses who are allowed to hand out HIV drugs have to do. Moreover, says Gray, these health workers will have to be guided by psychiatrists. “Mentoring is going to be really important, not only during the training, but as an ongoing referral mechanism for those nurses who will be asked to take care of patients with mental conditions.”
So, what are the dangers of shifting some of the psychological care for people with HIV to nurses, and will it be as effective as when ARVs were put in nurses’ hands?
Mia Malan spoke to Francois Venter, a doctor who has lived through HIV for the past two decades with his patients and the director of Ezintsha at Wits University, to find out in the latest episode of Health Beat, Bhekisisa’s monthly TV show.
Watch the full interview
Mia Malan (MM): Does making medicine easier to access lead to patients taking it more consistently?
Francois Venter (FV): The transition from knowing your diagnosis to learning your status and then being able to pick up your medicines is important. We’ve learned that getting your diagnosis fast, starting the treatment — usually on the same day in South Africa — and getting your medicines from somebody who knows what they’re doing, in the same place, near your home, facilitates people taking the tablets. We’ve now got millions of people successfully on therapy because of that.
MM: Tell us about the time before nurses were allowed to prescribe ARVs.
FV: When the state programme started on 1 April 2004, we started in hospital clinics, with doctors dispensing [the pills to] initiate the therapy. There was a big deal about adherence in many parts of the country — people often came back months from when they were started [on treatment]. There was a big song and dance [about] starting [treatment]: lots of blood tests, lots of adherence visits. Then, when patients were ready after they’d been diagnosed and they’d come back a couple of times [for follow-up checks], they would get their drugs prescribed by a doctor. Then they [had to] come back several times as the drugs [took] hold, to finally get a couple of months’ therapy (three, or in some cases six months’) at a time. It really was a big process, and it took us a long time to get up to 100 000 patients. The big scale-up took place when we said: “Nurses can do this and counsellors could diagnose people.” We gained more confidence with the tests, we gained more confidence with the drugs. Nurses at primary healthcare clinics started to initiate the therapy and we realised that it was [a] safe [approach]. Now we’re in an era where we’re saying even pharmacists must be able to prescribe these drugs. It’s a whole transition: saying the drugs are so safe and so good that we should try to get [their dispensing down] to the lowest level [of medical staff] possible.
MM: Making the shift from having a very high level of health worker, such as a doctor, prescribe ARVs to lower levels of staff, such as nurses and pharmacists, has helped us to make these drugs more accessible and to put more people on treatment. Will we see the same benefits in the case of psychiatric drugs?
FV: I hope so. Mental health is grossly underdiagnosed and undertreated. We have therapies, we know how to diagnose [conditions]. We need to push these therapeutics into the hands of people who are able to, firstly, diagnose and, secondly, hand them out. We don’t have nearly enough doctors and nurses in the country, and if we keep saying [prescribing these medicines is] going to be left in the hands of the highest tier of medical care, it means the people who need them aren’t going to get them. So we really need the same approach to mental health as we have for HIV. I think that’s what HIV has taught [us about] a lot of chronic diseases: you need to devolve these therapeutics to the level at which people need them.
MM: If we make these medicines, such as antidepressants or anxiety drugs, more accessible, isn’t there a danger that they can be abused?
FV: People are often concerned about this. I think you just need to be sensible and look at which strategy you’re dealing with. What are the dangers? All drugs have side effects. So, you need to consider what are the benefits to society and what are the harms. Then train the people who are handing them out [about the effects]. ARVs are a good example [of how to do this], and I think the same thing needs to be done with each group of mental health drugs. Some of them do need to be in the right hands, and perhaps that’s a group [handled only by] psychiatrists. Or there are some that might need to be handed out only by doctors. But there are many that can safely be handed out by lower tiers of medical staff, and [which] people can get a lot of benefit from.
Linda Pretorius is Bhekisisa’s content editor. She has a PhD in biosystems from the University of Pretoria has been working as a science writer, editor and proofreader in the book industry and for academic journals over the past 15 years. At Bhekisisa she helps authors to shape and develop their stories to pack a punch.
