Process evaluation of the HIV+D intervention for integrating the management of depression in routine HIV care in Uganda

HIV/AIDS continues to be one of the leading global health challenges, having claimed over 40 million lives so far. People infected with HIV are more likely to develop depression, leading to several negative behavioural and clinical outcomes. Studies have reported exceptionally high prevalence of depressive symptoms among people living with HIV/AIDS (PLWHA), making a case for integrating mental healthcare in routine HIV care. The HIV+D program was implemented in Uganda as an intervention model for integrating the management of depression in HIV care. Process evaluation was carried out to understand the contextual factors and explain the outcomes of the intervention. This was a qualitative study, conducted in 28 out of the 40 public health facilities in 3 districts, where the intervention was undertaken. A total of 82 participants, including the implementers and beneficiaries of the intervention were purposively selected for key informant interviews and focus group discussions. Conventional content analysis was done focusing on 6 aspects including reach, effectiveness, acceptability, implementation fidelity, maintenance (sustainability) and contextual factors that affected the intervention. The intervention was well received and believed to address a real need of the intended beneficiaries; many of whom described it as a program for helping the depressed PLWHA to deal with their depression. The implementers were said to have adhered to the intervention protocol, without major program adaptations, suggesting strong implementation fidelity. The respondents cited several positive health outcomes that resulted from the intervention, for both the beneficiaries and the implementers. Several contextual factors affected the implementation. Although it met the beneficiaries’ approval, and was considered relevant and acceptable, they expressed uncertainty over sustainability of the intervention in a health system characterized by understaffing, resource constraints and several other challenges. The intervention was generally implemented as intended, resulting in several positive health outcomes.