Task-shifting 'gold standard' clinical assessment and safety planning for suicide risk among people living with HIV: A feasibility and fidelity evaluation in Tanzania.

Abstract

ABSTRACT Background: Suicide is a leading cause of death among people living with HIV (PLWH) worldwide, with suicide deaths occurring twice as frequently among PLWH than among the general public. In Tanzania, resources for mental health care are sorely lacking, with 55 psychiatrists and psychologists providing treatment for 60 million people. In light of this shortage, no specialists play a crucial role. The objective of this study was to assess feasibility of implementing task-shifted screening, assessment, and safety planning for suicide risk among PLWH. Setting: Two adult HIV clinics in Kilimanjaro, Tanzania. Methods: Registered professional nurses in the HIV clinics were trained to administer brief screening of suicidal ideation in the past month. Patients experiencing suicidal ideation were referred to bachelor's-level counselors for further assessment and safety planning, supervised by specialist providers who reviewed audio recordings for quality assurance. Results: During 180 days of implementation, nurses screened patients attending 2745 HIV appointments. Sixty-one (2.2%) endorsed suicidal ideation and were linked to further assessment and safety planning. We cross-checked screening with clinic attendance logs on 7 random days and found high fidelity to screening (206 of 228 screened, 90%). Quality assurance ratings demonstrated key assessment pieces were consistently completed (mean = 9.3/10 possible), with "Good" to "Excellent" counseling skills (mean = 23.7/28) and "Good" to "Excellent" quality (mean = 17.1/20), including appropriate referral for higher levels of care. Conclusions: Brief screening can be implemented and paired with task-shifted counseling to facilitate high-quality assessment of suicide risk. This model shows excellent potential to extend mental health services for PLWH in low-resource settings.