Patient experiences and contextual appropriateness of universal screening for depression and suicide risk in HIV care: A qualitative study in Tanzania

Kim Madundo ^1,2* Mirlene Perry ³ Judith Mwobobia ⁴ Ismail Shekibula ⁵ Elizabeth F Bright ^1,2,6 Clotilda S Tarimo ⁶ Victor Katiti ⁶ Blandina Theophil Mmbaga ^1,2,6 David Goldston ⁷ Michael Relf ^3,5 Brandon Knettel ^3,5

• ¹ Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
• ² Kilimanjaro Christian Medical Centre, Moshi, Arusha, Tanzania
• ³ School of Nursing, Duke University, Durham, North Carolina, United States
• ⁴ Brown School, Washington University in St. Louis, St. Louis, Missouri, United States
• ⁵ Duke Global Health Institute, Duke University, Durham, North Carolina, United States
• ⁶ Kilimanjaro Clinical Research Institute (KCRI), Moshi, Tanzania
• ⁷ Department of Psychiatry & Behavioral Sciences, School of Medicine, Duke University, Durham, North Carolina, United States

Depression and suicidal thoughts and behaviour are remarkably common among people living with HIV worldwide, leading to a higher burden of disease, poor HIV care engagement, and death. Suicidal behaviour is criminalized in 20 countries worldwide, including Tanzania, where context-appropriate interventions are lacking. We describe the experiences of patients who were screened for depression and suicidal ideation by HIV clinic nurses, and how the socio-cultural context influences these experiences. This screening was the initial procedure in a randomized controlled clinical trial and parent study aimed at reducing suicide and depression and improving HIV care engagement in Kilimanjaro, Tanzania. We conducted in-depth interviews (IDIs) with 20 people living with HIV.Interviews were held 3 months post-enrollment of participants. Data was collected from July to November 2023. We referred to a brief screener developed for the trial, combining the PHQ-2 for depression and one question on suicidal ideation. IDIs focused on the experiences and appropriateness of being screened for depression and suicidal ideation, factors influencing these challenges, and opinions on the illegality of suicidal behaviour in Tanzania. Data was analyzed using Nvivo 14. Thematic analysis approach was utilized to identify, review and, label codes. Differences were resolved by the first three and final authors. Our findings revealed high appreciation for the screening and occasional initial discomfort. Stigma, misinformation, and poverty contributed to mental health challenges. Patients favoured abolishment of laws against suicide due to their hindering support-seeking and impracticality for individuals in mental health crises. In a mental health resourcelimited setting, these findings highlight the need for targeted and integrated non-specialist screenings and interventions and outsourcing HIV and mental health support beyond healthcare facilities. Further research is needed to assess the sustainability of screening.