Qualitative evaluation of the multilevel influences on mental health and barriers and facilitators to care among Mozambican adolescents with HIV

Mental health problems among adolescents with HIV (AWH) serve as a significant barrier to achieving optimal HIV health outcomes, but the mental health treatment gap for AWH remains large, particularly in the highest HIV-burden settings. We examined perceptions of mental health problems, influences on mental health, and barriers and facilitators to mental health care for AWH in Mozambique, a lower-resource, high HIV-burden context. We conducted focus groups with AWH (N = 7) and caregivers (N = 5) and key informant interviews with mental health and primary care providers (N = 9) and mental health and HIV policymakers (N = 5). Semi-structured guides were based on a tailored Socioecological Model. We analyzed data by the best fit framework approach. Participants highlighted depression and anxiety as priority mental health problems. Both positive and negative influences on AWH mental health were found at the community-, family-, and individual-levels. Barriers to care included the low policy-level priority of mental health, limited accessibility and resources of clinics, and low mental health awareness. Facilitators included the increased awareness of association between mental health and HIV-related outcomes, mental health care integrated with HIV services and in community settings, and providers with attentive and empathic disposition. Findings suggest that multilevel interventions focusing on both risk and resilience factors may be most effective at improving AWH mental health. Moreover, alternative intervention delivery methods should be considered, including community-based services and peer providers. Along with informing Mozambican policy and programming, these findings may be applicable in other high HIV-burden settings to promote AWH mental health and HIV outcomes.