Expert consensus on barriers, facilitators and digital strategies to improve mental health service access for adolescents and young people living with HIV in Zambia 2025: A Delphi study

This 2025 Delphi study involving Zambian experts reached a strong consensus on key barriers, facilitators, and digital strategies—such as decentralizing services, integrating mental health into HIV care, and implementing secure, low-data mHealth tools—to improve mental health service access for adolescents and young people living with HIV in Zambia.

The Gist

Imagine Zambia's healthcare system as a massive, bustling city. For young people living with HIV (let's call them "AYPLHIV"), this city has a very specific problem: the "Mental Health Department" is locked in a fancy, high-rise building in the city center, while most of the young people live in the outskirts. Getting there is expensive, the bus rides are long, and the doors are hard to find. Meanwhile, the "HIV Department" is right in their neighborhood, but it doesn't have a Mental Health counter inside.

This paper is like a town hall meeting where ten of Zambia's top experts (doctors, nurses, tech wizards, and program leaders) sat down to figure out how to fix this broken map. They used a method called a Delphi study, which is essentially a structured game of "Yes, No, Maybe" to reach a group agreement.

Here is what they discovered, broken down into simple stories:

1. The Roadblocks (Barriers)

The experts agreed that there are huge walls stopping young people from getting help:

• The "Double Stigma" Wall: It's like wearing two heavy backpacks. One says "I have HIV," and the other says "I'm sad or anxious." Many young people are so afraid of being judged for both that they hide in their rooms instead of seeking help.
• The "Empty Pocket" Barrier: Even if they want to go, they can't afford the bus fare to the city center, or they can't take time off work/school.
• The "Magic vs. Medicine" Confusion: Some communities believe sadness or anxiety is caused by witches or curses, not by biology. This leads families to seek spiritual help first, delaying medical care.
• The "Missing Guides" Problem: There aren't enough trained mental health guides (doctors and counselors), especially in rural villages.

2. The Shortcuts (Facilitators)

To get past the walls, the experts built a new map with clear shortcuts:

• Bring the Clinic to the Village: Instead of making kids travel to the city, put mental health check-ups right inside the local HIV clinics and community health centers. It's like opening a "Mental Health Kiosk" right next to the "HIV Medicine Dispenser."
• The "Safe Zone" Rule: Services need to be "Youth-Friendly." Think of it as a secret club where no one judges, no one gossips, and your secrets are safe.
• Peer Power: Train young people to help other young people. It's like having a "Big Brother" or "Big Sister" who has been through it and can say, "I get it, and here is how you survive."

3. The Digital Bridge (mHealth Strategies)

The experts were very excited about using phones as a bridge to cross the distance. They imagined a super-app that acts as a digital lifeline. However, they said this app must follow strict rules to work:

• The "Offline Mode" Rule: The app must work even when there is no internet or when data is too expensive. It needs to be like a flashlight that works without batteries.
• The "Fort Knox" Rule: Privacy is everything. The app needs strong locks (encryption) so that no one—not even family members—can see what the user is typing.
• The "Local Flavor" Rule: The app can't just be in English. It needs to speak local languages, use local stories, and even include sign language or videos so everyone understands.
• The "Bridge to Reality" Rule: The app shouldn't just be a chatbot; it must have a clear button to connect the user to a real human counselor if things get too heavy.

4. What They Couldn't Agree On

Out of 29 ideas they discussed, they agreed on 27 of them. There were two things they couldn't settle:

• Is the current counseling good enough? Some experts said "Yes, in some places," while others said "No, it's terrible." It depends on which village you are in.
• Is the new Mental Health Law working? Most said the law exists but isn't being used well due to lack of money, but a few thought some local progress was being made.

The Bottom Line

The experts concluded that to help young people living with HIV, Zambia needs to decentralize (bring services closer to home), integrate (mix mental health with HIV care), and digitize (use secure, offline-capable apps).

They aren't promising a magic cure yet. Instead, they are handing policymakers a blueprint. It's a clear set of instructions on how to build a system where a young person doesn't have to choose between their HIV treatment and their mental health—they can get both in one safe, accessible place.

Technical Summary

Technical Summary: Expert Consensus on Barriers, Facilitators, and Digital Strategies for AYPLHIV Mental Health in Zambia

Problem Statement
Adolescents and young people living with HIV (AYPLHIV) in Zambia face a high burden of common mental disorders, including depression, anxiety, and behavioral difficulties. These conditions are critically linked to poor antiretroviral therapy (ART) adherence, unsuppressed viral loads, and increased loss to follow-up, thereby undermining long-term HIV outcomes. Despite this, mental health services in Zambia remain fragmented, centralized, and weakly integrated with HIV care. While national policies (e.g., the Mental Health Act of 2019 and the Digital Health Strategy 2022–2026) signal a commitment to integrated care, implementation at the district and community levels has been slow. There is a lack of locally generated evidence to prioritize feasible system, service, and digital strategies specifically for AYPLHIV.

Methodology
The study employed a two-round Delphi method to generate expert consensus on barriers, facilitators, and digital strategies.

• Participants: Ten Zambian experts were purposively sampled, representing diverse backgrounds including psychiatry, psychology, mental health nursing, HIV program management, and digital health. Participants had 5–25 years of professional experience.
• Round One (Qualitative): Conducted between September 1–10, 2025, this round utilized a structured, open-ended questionnaire to identify barriers, facilitators, and mHealth design priorities. Responses were thematically analyzed using Ligre 6.5.1 software. An inductive–deductive hybrid approach was used to code data, resulting in 29 concise, single-concept statements.
• Round Two (Quantitative): Conducted between September 15–20, 2025, experts rated the 29 statements on a five-point Likert scale (1 = strongly disagree to 5 = strongly agree).
• Consensus Criteria: Consensus was defined a priori as: (i) ≥70% of experts rating a statement as 4 or 5 ("agree" or "strongly agree"); and (ii) an interquartile range (IQR) ≤1.
• Ethics: The study received approval from the University of Zambia Biomedical Research Ethics Committee and the National Health Research Authority.

Key Contributions and Results
The study achieved consensus on 27 of 29 statements (93%). The findings are categorized into four domains:

1. Barriers to Access:

   • Systemic: The mental health program is fragmented and under-resourced, with services concentrated in tertiary urban facilities. Integration of mental health within HIV care is inadequate.
   • Socioeconomic: Poverty and transport costs are major hindrances, particularly for rural AYPLHIV requiring multiple visits to centralized sites.
   • Social/Cultural: Stigma related to both HIV and mental illness creates a "double stigma" that discourages help-seeking. Cultural beliefs attributing mental illness to witchcraft and restrictive gender norms (e.g., expectations of male emotional stoicism) further delay care.
   • Workforce: There is a shortage of trained providers, especially in rural districts, and low mental health literacy among adolescents and caregivers.

2. Facilitators and System-Strengthening:

   • Decentralization: Experts strongly agreed on the need to decentralize services, integrating mental health assessment and basic interventions into primary health care and ART clinics.
   • Service Quality: Youth-friendly, confidential, and stigma-free services are essential.
   • Peer Support: Training adolescents as peer advocates and utilizing peer-led initiatives are critical for engagement and normalization of mental health conversations.
   • Collaboration: Multisector collaboration (health, education, social protection, youth, and telecommunications) and the involvement of faith-based and traditional leaders are vital for sustainable implementation.

3. Digital and mHealth Strategies:

   • Role of mHealth: Mobile applications and SMS platforms are endorsed as complementary tools for psychoeducation, self-screening, and connecting users to human support.
   • Design Requirements: To be effective, tools must ensure robust confidentiality (PINs, biometrics, encryption) and comply with the Data Protection Act. They must function offline or with low data requirements, support multiple local languages, and include audio-visual content.
   • Inclusivity: Features such as sign-language support and content reflecting Zambian values and storytelling are necessary for acceptance.
   • Partnerships: Collaboration with telecom companies to reduce data costs is essential for affordability.

4. Non-Consensus Items:

   • Two statements did not reach consensus: one regarding the adequacy of counseling in public facilities (due to variable experiences across provinces) and another regarding the specific strength of recent local initiatives under the Mental Health Act (indicating mixed views on progress).

Significance and Claims
The paper claims to provide a pragmatic framework for policymakers and implementers to integrate mental health and mHealth into Zambia's HIV prevention, treatment, and care programs. By synthesizing expert consensus, the study identifies clear priorities for addressing structural barriers (stigma, poverty, centralization) and leveraging digital tools to close the mental health treatment gap for AYPLHIV.

The authors position this work as a foundational step for implementation research, noting that while the consensus reflects expert judgment, further research is required to test the feasibility, acceptability, and effectiveness of the proposed strategies. The study emphasizes that the identified priorities are widely endorsed among national experts and align with global frameworks like the WHO's Mental Health Gap Action Programme (mhGAP), but must be adapted to the specific context of Zambia's resource-limited setting.