Drivers of chronic depressive and harmful alcohol use symptoms among adults living with HIV in Lesotho: pathways for integrated interventions

Mental health problems are prevalent among people with HIV (PWH) in Southern Africa. However, mental health problems are substantially under-diagnosed and under-treated in this setting. This study explores the drivers, explanatory factors, and coping mechanisms of mental health problems among PWH in Lesotho who have lived experience with depressive symptoms and/or alcohol use problems and attempts to contextualize the findings to local realities and norms. Semi-structured interviews were conducted in Butha Buthe (peri-urban) and Mokhotlong (rural) districts in Lesotho at district- and village-level health facilities with 28 PWH recruited based on past year’s record of depressive symptoms (n=22), harmful alcohol consumption (n=4), or both (n=2). Thematic analysis identified overarching themes, which were synthesized into a conceptual model. Economic and interpersonal challenges were perceived as drivers of mental health problems. Perceived lack of tangible resources and agency to alleviate these problems led participants to feel helpless and experience chronic depressive symptoms. Participants described coping with these symptoms through harmful alcohol use, which is often unaddressed due to local norms surrounding alcohol consumption. Chronic depressive symptoms and harmful alcohol use reduced individuals’ cognitive capacity to resolve their economic and interpersonal problems, reinforcing the cycle between these problems and corollary mental health problems. Participants suggested three intervention areas to target this cycle in their community: economic empowerment, social engagement in the form of group activities, and public education coupled with professional counseling to raise awareness and support for mental health problems. Findings reveal that PWH in Lesotho view economic and interpersonal problems as the main drivers of chronic depressive symptoms and harmful alcohol use, which only serve to reinforce the underlying problems. Addressing these drivers alongside HIV care may be effective in reducing the depression and alcohol use burden experienced by this population. • Economic and interpersonal hardships are viewed as drivers of depressive symptoms. • Harmful alcohol use is a coping mechanism for depressive symptoms. • Future interventions should address economic empowerment and social engagement.