Christina Chandra is a Master of Public Health (M.P.H.) in Global Epidemiology student at the Rollins School of Public Health at Emory University. As part of her graduate studies, she conducted research with amfAR’s TREAT Asia program in 2019, surveying and interviewing HIV care providers on mental health service integration for adults living with HIV in Bangkok, Thailand. She previously interned with amfAR through the Allan Rosenfield HIV/AIDS Public Policy Internship and Fellowship Program. For her work with TREAT Asia, Christina was honored by the Journal of Public Health Management and Practice as one of the “students who rocked public health” in 2019.
(Left to right) Vice President and Director of TREAT Asia Dr. Annette Sohn, Christina Chandra, Project Manager Tor Petersen, and TREAT Asia Director of Research Dr. Jeremy Ross
How did you become interested in the relationship between HIV and mental health?
I became interested in the relationship between HIV and mental health while conceptualizing this project with TREAT Asia and learned that mental health can impact clinical outcomes of people living with HIV. I believe that mental health is an important aspect of any person’s overall health, but this project brought to my attention the multiple stigmas that people in the Asia-Pacific region may face as a result of their HIV status, gender identity, drug use, or sex work that can further impact their mental health (which is also stigmatized). Once I was in Bangkok conducting interviews and meeting with physicians who treated patients of all ages living with HIV, I realized that providers were very much concerned about mental health and were motivated to address it.
Can you describe your research project with TREAT Asia?
Our project aimed to assess the extent of integration of mental health services—including screening, diagnosis, and treatment—for common mental health problems in adult HIV care settings in Bangkok. We were also interested in facilitators and barriers to integrating these services. To answer our questions, I conducted key informant interviews and surveyed HIV care providers, which included community health workers, counselors, nurses, peer educators, and physicians.
What were your findings from these surveys and interviews? Did you garner any surprising or new insights?
We found that the integration of diagnosis and treatment of mental health problems lagged behind mental health screening. This meant that screening for mental health problems—including depression, anxiety, and substance use—was being done by HIV care providers. Then patients who screened positive for severe mental health problems were often referred to a specialist for diagnosis and treatment. Providers noted that referrals may be a concern if mental health problems worsened before the individual’s appointment or if they did not go to their scheduled appointment. Many providers suggested that having a specialist within the HIV clinic would be preferable. We also found that task-shifting of screening was already occurring among counselors and nurses (i.e., the burden of mental health care was not solely on physicians) and that providers we surveyed were receptive to training. Having established clinic protocols and care guidelines were identified as facilitators to mental health service integration, while societal stigma seemed to be a barrier.
How do you envision building on this research?
I think this research could be expanded by evaluating the feasibility and effectiveness of two different methods of mental health service integration in Bangkok: 1) having an “in-house” specialist available within HIV care settings, or 2) training various providers in screening for mental health problems as well as diagnosing and treating common mental health problems. Additionally, this project centered on provider perspectives, so I think it would be helpful to hear the perspectives of people living with HIV who are seeking mental health care at these clinics and understand their preferences.
How did your work with TREAT Asia connect to your research interests at Emory?
For my M.P.H. thesis, I am also looking at mental health and HIV, but from the perspective of prevention. I am using data from a cohort study that followed young, black men who have sex with men in Atlanta conducted by Programs, Research & Innovation in Sexual Minority Health (PRISM) at Emory to examine the association between depression and anxiety symptoms with condomless anal sex. Previous studies have reported mixed findings on whether mental health and sexual risk behavior are related, and I am interested in exploring that further in my thesis.
What do you plan to do after you finish your graduate studies?
I have applied to Ph.D. programs in epidemiology, and I hope to hear positive news over the next couple months about where I will continue my studies.