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I-TECH Supports Mental Health in Ukraine Amid War

Post categories: HIV Counseling and Testing Mental Health PrEP Ukraine
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                 Image by Денис Марчук

Since the Russian invasion and onset of full-scale war in 2022,  the International Training and Education Center for Health (I-TECH) has been strengthening its capacity to provide support for healthcare workers (HCWs) in Ukraine. Key support programming has included a mental health project targeting both HCWs and people living with HIV (PLHIV), delivered as part of its national Pre-exposure Prophylaxis (PrEP) Program.

The Ukrainian population is experiencing high rates of post-traumatic stress disorder (PTSD) and other mental health disorders as a result of the war in Ukraine. One recent study found that 30.8% of its Ukrainian respondents met criteria for elevated risk of PTSD, with internally and externally displaced people showing significantly higher rates of risk.1 Another found that 52.7% of its Ukrainian sample aged 18 years or older showed symptoms of psychological distress, 46.8% of depression, and 12.1% of insomnia.2

“As time goes on, the greater the need for support for healthcare professionals becomes.”
– Olena Frolenkova, counselor

These numbers include not only the general population, but also the physicians, nurses, and other HCWs who continue supporting their fellow Ukrainians amid the war. These professionals put their own safety and mental health on the line every day to provide compassionate care to their communities in a time of immense crisis.

“Our medical doctors and nurses remain on the frontlines of the humanitarian responses, dealing with unimaginable loss and trauma daily, both professionally but also personally,” says Anna Shapoval, EdD, Country Representative for I-TECH Ukraine.

By mid-2024, the growing team of I-TECH counselors has conducted 325 planned individual online supportive supervision, including counseling, sessions for HCWs. Out of those, 45% of sessions were requested by HCWs due to a complex psychological and emotional condition. Key topics for supervision sessions were the psycho-emotional conditions of medical providers, discussions of actual working cases, management of complex consulting cases, and team interactions.

At the same time more than 3,500 PLHIV were screened for depression, out of them around 10% were diagnosed with such and referred for specialized care as part of this project. I-TECH’s team also invests significant time and resources into strengthening the counseling capacities of the HCWs and sharing information on the importance of mental health and related services available in each region of Ukraine among patients of its PrEP Program.

In recent months, the I-TECH team in Ukraine has expanded mental health program activities within its PrEP Program and hopes to continue this expansion through enhanced mental health education, counseling, and supervision for HCWs, focus on additional target groups such as military, veterans and their family members, and other related activities in 2025.

“The I-TECH Ukraine team is immensely grateful to its funders – the U.S. Health Resources and Services Administration (HRSA) through the President’s Plan for Emergency AIDS Relief (PEPFAR) in Ukraine – for their proactive position in regard to the mental health needs of HCWs, PLHIV, and PrEP patients in Ukraine,” says Ms. Shapoval. “As a result, since 2022 I-TECH Ukraine has received additional funding and guidance from its partners that have enabled immediate tailored response and development of the mental health programming that now represents a vital part of our daily activities in Ukraine.”

Ongoing expansion is critical, says Ms. Shapoval, to meet the increasing needs of both HCWs and their patients. Natalia Tiuleneva, lead mental health counselor with I-TECH, agrees: “Currently, medical specialists in Ukraine see a large number of patients who come to their appointment not only with somatic problems, but also with emotional flooding due to the war,” says Ms. Tiuleneva. “With each patient, the doctor experiences an individual patient war each time. This is a big mental burden…. Doctors complain of fatigue and the inability to process so much mental pain.

“It is important for us to save each other,” she continues. “It is important to protect highly qualified specialists. People are capable of a lot when they have a place where their resilience will be noticed and preserved. This culture of professional support in the medical community is promoted by our program, and it is slowly taking root.”

A couple of these examples are below.

A mother, a daughter, and their doctor make progress

A PrEP patient arrived at her doctor’s appointment with her 13-year-old daughter, who had been raped by her HIV-positive stepfather. While the offender was under investigation by the police, he continued to live in their shared housing. After testing, the girl was found to have HIV.

The doctor provided highly professional, compassionate support and consultation, but after the appointment she noted that her personal psychological condition had worsened, and she could not sleep at night. She contacted an I-TECH psychologist for help.

During the session, the psychologist led the doctor through a series of breathing and grounding exercises to lower her stress level. Afterward, she outlined recommendations to be shared with the patient and her mother:

  • To ensure the safety of the girl, she and her mother should end all contact with the offender and find another place to live.
  • The mother should contact a psychologist for her daughter that specializes in sexual trauma.

At a follow-up appointment a month later, the doctor, mother, and child worked together on assimilating the daughter’s experience, a therapeutic method that has shown to decrease the intensity of symptoms.3 As a result of the doctor’s interventions, as well as the help of other specialists, the child is now receiving antiretroviral therapy (ART) and psychological counseling, and she and her mother were able to move to a shelter for survivors of violence.

“I am inspired by the strength in these stories. The power to be human, the power to help others, the power to overcome life’s challenges and trials, the power to become stronger.”
—Diana Martyniuk, counselor

For her part, the doctor’s sleep has improved, and her stress levels have decreased. “Finally, I can consult [the mother and child] as my regular patients,” she says.

Empathy leads to overload, and a request for help

During a scheduled session with an I-TECH psychologist, a doctor reported that she was in a difficult emotional state due to the stress of war. The doctor was worried because she often woke up at night with an accelerated heartbeat and a feeling that something terrible was about to happen. Often, she could not fall asleep for a long time and felt overall depressed.

She then mentioned a challenging case from her clinical practice that had been weighing on her heavily.

A 50-year-old patient of hers had been in serious condition with COVID-19. Every day, the doctor was tasked with telling the woman’s son, who served in the military, that his mother’s condition was getting worse. Over time, providing quality support and feeling compassion for the patient and her son had led to emotional overload and exhaustion for the doctor. When her patient died, the son’s grief—and even his gratitude toward her—compounded the doctor’s mental overwhelm.

To address these issues, the physician turned to the I-TECH psychologist again, requesting an additional session. After practicing self-regulation exercises shared during the session, the doctor reported that her sleep stabilized, her well-being improved, and her mood fluctuations decreased.

In a follow-up text to her counselor, the doctor reported: “I started working again, tomorrow it is going to be two weeks…. I completed the activities we discussed. I feel better. I have a different mood, I feel calmer.”

“During the hostilities in Ukraine, the burden on all doctors has increased,” says counselor Nadiya Bruyaka. “In addition to the increase in the number of patients and the severity of their personal stories, other challenges have been added that they had no experience with before: blackouts, Internet outages, air raids, distance learning of one’s own children and anxiety for them during air raids, the presence of relatives and friends in the Armed Forces and increased anxiety for their lives, feelings of uncertainty and helplessness.

“It’s all exhausting,” she continues, “and it is during sessions that doctors and nurses have the opportunity to share their personal condition, understand it, and get support and practical recommendations.”

 

1 Ben-Ezra M, Goodwin R, Leshem E & Hamama-Raz Y. (2023). PTSD symptoms among civilians being displaced inside and outside Ukraine during the 2022 Russian invasion. Psychiatry Res. 2023 Feb:320:115011. doi: 10.1016/j.psychres.2022.115011. Epub 2022 Dec 17.
2 Xu W, Pavlova I, Chen X, Petrytsa P, Graf-Vlachy L & Zhang SX. (2023). Mental health symptoms and coping strategies among Ukrainians during the Russia-Ukraine war in March 2022. Int J Soc Psychiatry. 2023 Jun;69(4):957-966. doi: 10.1177/00207640221143919. Epub 2023 Jan 4.
3 Basto IM, Stiles WB, Rijo D, and Salgado J. Does assimilation of problematic experiences predict a decrease in symptom intensity? Clin Psychol Psychother. 2018 Jan-Feb; 25(1): 76–84.

Two Years of War in Ukraine: I-TECH and Healthcare System Resilience

Post categories: eLearning/Distance Learning Key Populations Lydia Chwastiak Mental Health PrEP Ukraine
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Alyona Ihnatiuk, Strategic Information Lead at I-TECH Ukraine, discusses the areas of active Russian hostilities and shelling in Ukraine.

A version of this piece was first posted on the University of Washington (UW) Department of Global Health’s (DGH) website. Article adapted and re-posted with permission.

On March 28, 2024, the International Training and Education Center for Health (I-TECH), the UW Behavioral Research Center for HIV (BIRCH), and the UW Department of Global Health (DGH), hosted a conversation with two critical members of the I-TECH Ukraine team, Oksana Danylenko, MD, MPMA, and Alyona Ihnatiuk, MPH.

During Two Years of War in Ukraine: I-TECH and Healthcare System Resilience, Dr. Danylenko and Ms. Ihnatiuk presented on the impact of the war on critical infrastructure and I-TECH’s activities in Ukraine to address the impacts, including new challenges, needs, and new service delivery models, as well as calling upon action and support.

Dr. Danylenko has 20+ years’ experience working in HIV/AIDS prevention, treatment, policy, and guidelines and serves as a Strategic Clinical Lead at I-TECH in Ukraine. Ms. Ihnatiuk is a Strategic Information Lead at I-TECH Ukraine, focusing on developing public health interventions, M&E system frameworks, data analysis, and program evaluation.

The session recording can be found on the DGH YouTube channel.

Related Resources

National HIV Psychosocial Services Expansion in Trinidad and Tobago

Post categories: Differentiated Care Health Systems Strengthening HIV Care and Treatment Key Populations Lydia Chwastiak Mental Health Trinidad and Tobago
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In 2019, I-TECH conducted an on-site assessment at Trinidad and Tobago’s largest HIV treatment site. The findings of that assessment led to the establishment of an integrated psychosocial program at this site that has yielded favorable results. This further inspired the need for expansion of this psychosocial approach to other HIV treatment and care sites.

In 2022, I-TECH collaborated with the HIV/AIDS Coordinating Unit (HACU) of the Ministry of Health (MOH) to conduct a similar rapid assessment throughout the national treatment and care sites. The results reflected that there was a need for specialized staff to identify and treat common mental health and psychosocial concerns, as well as a standardized approach. Therefore, I-TECH is supporting the HACU to lead the expansion and strengthening of mental health and psychosocial (MHPS) service delivery for persons living with HIV at HIV treatment and care sites in Trinidad and Tobago. Goals include the standardization of psychosocial assessments to support the early identification of psychological distress, symptoms of co-morbid mental illness and psychosocial issues; as well as the standardization of the procedures for making interventions.

Activities include:

  • Developing a draft MHPS Protocol to include screening and intervention tools and psychosocial standard operating procedures (SOPs)
  • Establishing a standardized referral system
  • Training and supporting psychosocial team members in the use of the SOPs and all screening and assessment tools. Training will address areas of intimate partner violence, gender-based violence, and mental health challenges that are frequently encountered within the client population
  • Training and supporting psychosocial team members in data collection and reporting requirements
  • Training and capacity -building of psychosocial team members of the Psychosocial Coordination Unit being established by the HACU

Lydia Chwastiak

Lydia Chwastiak, MD, MPH

Lydia Chwastiak MD, MPH is a psychiatrist and internal medicine physician and Professor in the Department of Psychiatry and Behavioral Sciences and Adjunct Professor in Global Health in the University of Washington. Her research for the past 21 years has focused on improving the care and outcomes of people with chronic medical conditions and serious mental disorders. She has been a principal investigator (PI) or co-investigator on eight NIH-funded clinical trials of integrated care in both medical and community mental health settings, including MPI on the multi-center INDEPENDENT Study (R01 MH100390) which demonstrated the effectiveness of collaborative care for the treatment of depression among patients with poorly controlled type 2 diabetes in 4 diabetes centers in India.

At I-TECH, Dr. Chwastiak is also the PI on a large global HRSA-funded grant to support capacity building for sustainable HIV services in Jamaica, Trinidad and Tobago, India, Mozambique, and Ukraine (U91HA06801). The goal of Capacity Building Program is to improve health outcomes for people living with HIV (PLHIV) along the HIV care continuum by building sustainable health systems. The program seeks to improve the efficiency and client-centeredness of HIV care systems by strengthening the operational and adaptive capacities of health institutions and the health workforce; expand the use of evidence-based methodologies and best practice approaches to improve health outcomes for PLHIV; increase the functionality and coverage of innovative technology platforms to improve HIV service delivery, public health communication, and data use for decision making; and strengthen equitable collaborations between country governments, implementing partners and communities to achieve and sustain epidemic control.

In addition to her work with I-TECH, Dr. Chwastiak is Associate Director of the UW Behavioral Research Center in HIV (BIRCH), an NIMH-funded developmental AIDS Research Center and directs the Center’s Integrated Care Research Core. She also is the PI and co-director of the SAMHSA-funded Northwest Mental Health Technology Transfer Center (Northwest-MHTTC), which provides training and technical assistance to support the behavioral health workforce of HHS Region 10 (AK, ID, OR and WA) to disseminate and implement evidence-based practices for mental disorders.

I-TECH to Expand Psychosocial and Gender-based Violence Support in Trinidad and Tobago

Post categories: Caribbean Gender/Women & Girls Mental Health Pamela Collins Trinidad and Tobago
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From left to right: Conrad Mitchell, Program Coordinator, I-TECH Trinidad; Belinda White, Clinical Psychologist, I-TECH Trinidad; Heather Rodney, Chairperson, NACC Secretariat; Ian Ramdahin, Permanent Secretary, NACC Secretariat; Dr. Omoye Imoisili, Senior Public Health Analyst, HRSA; Aliyah Abdul Wakil, Strategic Information, HRSA; Alana Lum Lock Cardinez, Program Advisor, I-TECH Trinidad; Misti McDowell, Program Director, I-TECH headquarters.

Recently, representatives from the International Training and Education Center for Health (I-TECH) met with health officials in Trinidad and Tobago to discuss potential areas of support for strengthening the national response to HIV and AIDS in the country.

The meeting attendees discussed strengthening advocacy for people living with HIV (PLHIV); psychosocial support for vulnerable PLHIV; and providing services at the intersection of HIV and AIDS and gender-based violence (GBV).

With support from the Health Resources and Services Administration (HRSA), I-TECH has worked in Trinidad and Tobago since 2009, collaborating with the Ministry of Health and other partners to focus on healthcare worker training and technical assistance to improve the quality of care for PLHIV.

“I’ve always been impressed with the team and activities in Trinidad and Tobago,” says Misti McDowell, I-TECH Program Director, “especially the integration of much-needed mental health services into the HIV program.”

The assessment “Strengthening Delivery and Oversight of Mental Health and Psychosocial Services for PLHIV in Trinidad and Tobago” was completed by I-TECH and shared with the National AIDS Coordinating Committee (NACC), in an effort to identify future areas of collaboration. One of the intended outcomes is the establishment of a technical working group of national stakeholders who will collaborate with I-TECH to craft a strategy for implementing all priority interventions.

“The findings of this assessment revealed that there is a tremendous need for improved mental health support specifically in the areas of assessment and treatment throughout the national HIV treatment and care sites,” says Belinda White, Clinical Psychologist with I-TECH. “One treatment and care site reported that as much as 90% of its client population experiences symptoms of mental illnesses.”

The most common mental illnesses encountered within treatment and care sites include depression, anxiety, bipolar disorder and schizophrenia; substance use disorder is also common within the PLHIV client population. A key area of interest is the integration of the Collaborative Care Model into the already existing treatment and care system, in a manner that incorporates the unique features of each site. The Collaborative Care Model is an evidence-based approach to treating common mental health conditions (e.g., depression, anxiety) in primary care settings and was developed at the University of Washington.

I-TECH also assisted the NACC with the establishment of the National HIV Helpline and will continue to provide support over the next six months, while working to transition the program fully to NACC. This includes support for the HIV Helpline Coordinator and Active Listeners, as well as training of new Active Listeners.

“We must continue fighting the stigma associated with living with HIV,” says Conrad Mitchell, Program Coordinator. “It’s important to continue to battle misinformation and to have that coupled with positive true-life experiences. The Helpline–manned by persons living with HIV together, with HIV NGO advocates and allies–provides a unique opportunity to combat misinformation though empathy and education in direct, one-on-one engagements with the public.”

A 2017 Inter-American Development Bank (IDB) National Women’s Health Survey for Trinidad and Tobago[1] showed that more than 30 percent of women in Trinidad and Tobago had reported having experienced at least one incidence of either physical or sexual partner violence. The NACC is seeking support related to GBV and the risks it poses to the health and well-being of PLHIV. Activities would focus on raising awareness and providing resources and psychosocial support for vulnerable groups.

“There is a lack of general knowledge about GBV and what it entails among the public as well as in some health care settings,” says Ms. White. “There is an opportunity to yield enormously positive results by increasing the knowledge and insight of health care workers, and people living with HIV, regarding GBV.

“My hope is that the information that is shared empowers people living with HIV to advocate for themselves if they come to the realization that they are experiencing,” she continues, “and to make contact with the local resources that are available to receive the necessary support.”

I-TECH will also seeks to help strengthen civil society organizations through enrollment in I-TECH-developed courses such as UW Leadership and Management in Health, Fundamentals of Implementation Science, Project Management in Global Health, Global Mental Health, and Policy Development and Advocacy for Global Health.

[1] https://publications.iadb.org/publications/english/document/National-Women-Health-Survey-for-Trinidad-and-Tobago-Final-Report.pdf

 

I-TECH Presents Posters at AIDS 2020: Virtual

Post categories: Caryl Feldacker Cervical Cancer Gabrielle O'Malley HIV Care and Treatment Malawi Male Circumcision Mental Health Namibia Zimbabwe
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The International AIDS Society (IAS) virtually hosted their 23rd International AIDS conference (AIDS 2020: Virtual) on 6-10 July 2020. The AIDS 2020: Virtual theme was resilience, to celebrate and acknowledge the strength of the HIV community and the significant advances in treatment, while also addressing gaps in treatment, prevention, and care.

Representatives from the International Training and Education Center for Health (I-TECH) virtually presented the following posters with accompanying audio recordings:

In addition to the I-TECH representatives presenting their posters, representatives from the Centers for Disease Control and Prevention (CDC) and Health Alliance International (HAI) also presented data from I-TECH programs in Malawi and Mozambique.

Mental Health Integration (MhINT) Program in South Africa

Post categories: Mental Health Past Program South Africa
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In collaboration with the University of KwaZulu-Natal, and The Knowledge Translation Unit, I-TECH worked with the National Department of Health (NDoH) in South Africa to strengthen the integration of mental health services into routine chronic care within the primary health care system.

The Mental Health Integration (MhINT) program improves access to care for common mental disorders and benefits adherence and engagement in care, aligning with the UNAIDS 95-95-95 strategy. I-TECH provided technical assistant to the NDoH and district support partners (DSPs) as the MhINT Program was scaled-up in priority districts identified by the U.S. Centers for Disease Control and Prevention’s Global AIDS Program (CDC GAP), South Africa, through the President’s Emergency Plan for AIDS Relief (PEPFAR). I-TECH also supported the NDoH as it conducted an in-depth policy situation analysis to inform the development of a national policy incorporating the MhINT program.

Mental Health – A New Challenge for HIV Treatment in Ethiopia

Post categories: Ethiopia Health Systems Strengthening HIV Care and Treatment Mental Health
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I-TECH-supported HIV care and counseling in northern Ethiopia, in 2009. Photo courtesy of Julia Sherburne.

Although HIV patients in Ethiopia have greater access to antiretroviral therapy (ART) than they did a decade ago, ensuring that patients adhere to a full course of ART is still a major challenge. In response, in 2008, the International Training and Education Center for Health (I-TECH) launched a landmark HIV/AIDS Case Management program in several of the country’s regions where HIV prevalence was high.

This project was supported by the U.S. President’s Plan for AIDS Relief (PEPFAR), through the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA).

The goals of the project are to help control the HIV epidemic in Ethiopia, minimize transmission of HIV, and help HIV patients lead healthy lives. The project actively targets and engages patients considered to be likely non-adherents by assessing clinical, nutritional, domestic, and economic indicators. Those at risk of non-adherence are transferred to I-TECH-trained case managers located within ART clinics.

“ART taken for life is a challenge, but missing a few pills can cause a rapid decline in the health of a patient suffering from HIV. A discontinued course of ART will create a resistant strain of HIV that is much more difficult to treat,” says Misti McDowell, former Country Director for I-TECH Ethiopia.

Poor adherence can also mean high risk of transmission in the patient’s community. The Case Management program helps mitigate that risk.

A new screening tool

I-TECH quickly realized that many patients attending adherence counseling sessions were suffering from mental health issues, including depression, anxiety, and substance abuse. It was also understood that many health workers did not have the competencies or skills to adequately engage in conversation with patients about their mental and emotional welfare.

I-TECH formulated a mental-health screening tool for all ART patients to better assist patients with ART adherence and mental health issues.

“Many HIV patients in Ethiopia become overwhelmed by depression, and commit suicide. The mental health component to our work has helped to prevent these outcomes, and manage mental health issues related to HIV diagnosis,” says Dr. Manuel Kassaye, I-TECH’s Care and Treatment Programs Director.

Shared experiences can save lives

In Ethiopia, there are currently only 42 working psychiatrists catering to the needs of an estimated population of 93 million. “The country is in need of a strategy to deliver mental health services to people,” says Dr. Manuel. I-TECH-trained adherence case managers, working in partnership with hospital clinicians, have directly helped to address mental health issues related to HIV in Ethiopia.

The majority of case managers selected and trained by I-TECH have themselves been diagnosed with HIV, ensuring empathic relationships with their patients.

“To be a good adherence support worker, I believe it is necessary to have HIV,” says Mulugojam Yilikal, who was trained as a support worker by I-TECH in 2008. “The case worker will have enough experience to empathize with the patient, to help guide them through their mental and emotional issues.”

She adds that patients feel secure and comfortable talking to people who also have HIV. “By opening up and talking freely with us, it benefits their mental health, and their adherence to taking their medication.”

Mulugojam’s brother tragically committed suicide in 2007, after struggling to come to terms with his HIV diagnosis. “I know that if this support and counseling service [had been] available to my brother, he would have been saved from killing himself,” she says. “If a patient confides to a support worker that they want to take their own life, they can be prevented [from doing so] through counseling.”

Genet Behre, 30, is married and has a 5-year-old son. She discovered her HIV status during a pregnancy check-up in 2009. She immediately started taking ART and reluctantly disclosed the news to her husband—who subsequently left her. Once disclosure is made, there usually follows a period of emotional and mental distress that often leads to household dysfunction. “It was a terrible time when I first found out,” says Genet. “I was very distressed, and came into conflict with family and friends.”

After being screened for mental health, Genet was offered counseling and medical treatment for her depression and anxiety. “After six months, I had stopped fighting with my family,” she says. “My life is now stable again, my home life is peaceful, and I have an income selling injera. The counseling and medical support I receive has helped me to live like ordinary people, and not fear for the future.”

After counseling, new hope

A peer support group has been set up by I-TECH, in which patients have a platform to confide in others and speak openly without fear of being judged. Here, people are encouraged to share personal experiences and coping strategies. The group focuses on helping patients cope with the stigma associated with HIV, and overcome any barriers to ART adherence, including social and economic problems.

Zenabe Teklu, 35, silently sits with her I-TECH trained case manager at Gondar Hospital. Although she barely speaks, she is evidently happy to be in the reassuring company of her mentor. Zenabe had two children who both tragically died within six months of being born. After the departure of her husband in 2007, her mental health started to deteriorate. Then, after developing physical sores in 2007, she was tested for HIV, and promptly joined I-TECH’s case support program. However, between 2007 and 2013, she continued to suffer strong symptoms of mental disturbance and suicidal tendencies.

In 2013, I-TECH introduced the mental health screening service at Gondar Hospital. Up to this point, Zenabe was mistakenly told that her depression and suicidal thoughts were symptoms of ART medication. Zenabe started receiving the correct medication and counseling shortly after hospital staff members had completed I-TECH training in mental health screening.

Zenabe, who currently works as a cotton weaver, is happy to have turned a huge corner in her life with the support of I-TECH: “My life is stable compared to how I was before. I no longer feel full of anger and depression. I have experienced a lot of trauma, but the support I get from my case managers helps me to live a normal life”.