Mental health-a bridge not so far.

The world now faces the next step in HIV management. We are in an era beyond treatment and viral suppression. The widespread roll out of antiretroviral treatment and good HIV testing programmes within pregnancy might substantially change vertical transmission rates globally. Lifelong treatment and innovations, such as those financed by the Global Fund, provide a pathway— indeed a lifeline—for survival. Yet, the scars of an epidemic are deep. Exposure to trauma and loss can affect children and youth for many years. Interventions for such trauma are improving, but recent reviews suggest a need for more solid evidence. In The Lancet Global Health, Tonya Thurman and colleagues’ study provides a randomised controlled evaluation of an intervention for bereaved adolescent girls in South Africa. As such, it marks an important shift in the evidence base and contributes to the growing provision in this area as well as providing usable tools. Mental health effects of the HIV epidemic are not only a key consideration, but might have been neglected especially in contexts of greatest resource constraints. The infrastructure and provision of mental health services in low-income and middle-income settings needs urgent attention. This study—despite specific limitations— is a clear example of potential provision and a way forward. The study showed effective impacts of a brief therapeutic intervention, including significantly lower intrusive grief, depression, and behaviour problems, and higher support. The intervention was confined to those who were willing to be included. However, it is well established in the psychological therapies that motivation and willingness for support is a pre-requisite for successful intervention. The study was confined to adolescent girls—again clearly noting a gap for adolescent boys who might have equal need, but could require adjusted interventions and different strategies to both reach them and to do so effectively. There is a growing body of evidence showing the efficacy of complex interventions for improving wellbeing and reducing adolescent risk behaviour. A recent Cochrane review identified only 16 quality trials of psychological interventions for adults affected by HIV. The evidence base for adolescents is even less robust. Emerging reports show the nature of mental health burden experienced by adolescents and forms of effective provision, such as client centred approaches in Ethiopia. This study adds to the evidence base— especially for adolescents where the data are much more limited. It marks the importance of the mental health burden of bereavement on adolescents—especially heightened by the many parental deaths within high endemic HIV settings. The study also explored the links between mental health and behaviour and showed how a brief intervention could reduce intrusive grief as well as reduce adult reported behavioural problems. As such, this small study is an example of the next generation of vital interventions. Acknowledgement of mental health issues is needed—especially in children and youth, and an active attempt needs to be made to measure this and to provide responsive pathways for redress. Evidence based interventions that are theory driven and accessible within the local culture are do-able and do not need to rely on imported interventions— especially when those are costly. Many bereaved children and youth reside in the community and have little recourse to good psychosocial support, despite the fact that such care has been shown to be of benefit. This study highlights group interventions as a costeffective quality support provision. In low-income and low-resource settings, the urgency of physical survival, the presence of dire poverty, and the absence of skilled services and infrastructure has often resulted in a focus on physical survival. The time has now come for mental health to be given adequate attention. This will require investment in infrastructure and personnel. It will also require an approach to care that incorporates the importance of mental health. Bereavement provision for survivors of HIV-related deaths might reduce as treatment reduces death rates. However, many communities are still carrying the burden of HIV within their midst and interventions that can ameliorate suffering, depression, and emotional burden are sorely needed.