Acceptability and Feasibility of a Task-Shifted Collaborative Care Model for Depression and Anxiety in Primary HIV Clinics in the Philippines: A Qualitative Inquiry

Acceptability and Feasibility of a Task-Shifted Collaborative Care Model for Depression and Anxiety in Primary HIV Clinics in the Philippines: A Qualitative Inquiry | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Acceptability and Feasibility of a Task-Shifted Collaborative Care Model for Depression and Anxiety in Primary HIV Clinics in the Philippines: A Qualitative Inquiry Anna Maureen Dungca-Lorilla, Jennifer Mootz, Maria Isabel Melgar, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4780343/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 May, 2025 Read the published version in BMC Health Services Research → Version 1 posted 4 You are reading this latest preprint version Abstract Background Depression and anxiety can greatly impact the overall health of a person living with HIV (PLHIV). Management of mental health conditions should be an integral part of HIV care. The Collaborative Care Model (CoCM) is an evidence-based model of care that integrates mental health in primary care. This study aimed to assess the acceptability and feasibility of implementing the CoCM for depression and anxiety in HIV clinics in the Philippines using HIV counsellors as care managers. Methods We conducted a qualitative study by facilitating focus group discussions (n = 7) and key informant interviews (n = 18) with 53 HIV and mental health stakeholders, including PLHIV (n = 20), HIV counsellors (n = 11), physicians (n = 10), clinic heads (n = 4), policy makers (n = 4), and mental health providers (n = 4) from August 2021 to March 2022. Participants were recruited from 17 HIV clinics in the Philippines. We employed a thematic analysis using the Consolidated Framework for Implementation Research (CFIR) domains as themes. Results Almost all PLHIV participants were men (95%), with a mean age of 28 years old, while 58% of the other stakeholders were women, with a mean age of 44 and working in their field for an average of 8 years. Factors that influenced acceptability of the CoCM included the need for better mental health services, increasing access to mental health care and providing more holistic care. Participants expressed acceptability for HIV providers to do mental health screening and care due to the trust that had previously been built during their HIV care. Perceived barriers included inadequate numbers of psychiatrists, an overburdened and understaffed HIV workforce, low mental health knowledge among HIV providers, and implementation cost. For the CoCM to be feasible and more acceptable, mental health trainings, collaborations for improved access to psychiatrists (e.g., within and across clinics), clear care integration protocols, proper planning and pilot testing were recommended. Conclusion We found the CoCM to be acceptable among study participants as a way to integrate mental health in HIV care. Strategies including capacity-building for HIV providers and strengthening of health systems are needed for the CoCM to be more feasible in HIV clinics in the Philippines. Introduction People living with HIV (PLHIV) have at least double the prevalence of mental health disorders than the general population, with depression and anxiety being the most common diagnoses ( 1 – 3 ). If left undiagnosed and untreated, these mental health conditions may have a negative impact on the HIV care continuum at screening and linkage to care, as well as on treatment adherence and overall quality of life ( 4 ). Bringing aspects of mental health care delivery into HIV care has been recommended to address the mental health needs of PLHIV and increase access to mental health care ( 5 ). The Collaborative Care Model (CoCM) is an evidence-based approach to integrating mental health services in primary care settings through a task-sharing strategy utilizing non-specialized providers. Based on large-scale adaptations mostly done in high-income settings, a report by the American Psychiatric Association and Academy of Psychosomatic Medicine summarized the four essential components of the CoCM ( 6 ). First, it is team-driven , defined as care led by a primary care physician with support from a care manager who is a behavioral health provider (e.g., social worker, licensed counsellor, nurses with mental health training) and a psychiatrist consultant. Care managers provide psychoeducation, brief behavioral interventions, or referral to specialist care. A psychiatrist consultant provides guidance to the team and is available to treat more complicated cases. Second, the CoCM is population-focused , meaning a patient registry is shared among the members of the care team to monitor responses to treatment and track patients who need more focused care. Third, the CoCM is measurement-guided through the use of standardized mental health symptom rating scales to guide assessment, formulate treatment plans, and enact monitoring. Finally, the CoCM provides evidence-based care, such as established psychotherapies and primary care provider-prescribed pharmacotherapy ( 6 , 7 ). The CoCM has effectively reduced the clinical burden of common mental health disorders, demonstrating short- and long-term improvements in depression as compared to the standard of care ( 8 – 11 ). The approach has been adapted and studied in diverse primary care settings to manage HIV and other chronic conditions, such as diabetes and coronary heart disease, in both high-income and low-and-middle income countries (LMIC) like India, Nepal, South Africa, and Vietnam ( 12 – 15 ). Barriers in implementing this model have included provider-level challenges (e.g., lack of knowledge and skills and engagement), patient-level issues (e.g., engagement and mental health stigma), organizational limitations (e.g., work flow issues, standardization of processes, workforce shortages), and insufficient financial resources ( 16 , 17 ). Recommendations to support successful implementation have entailed multi-disciplinary linkages across service sectors, stakeholder engagement, and strong leadership. In some settings, health workers from other disciplines were trained as care managers, such as in India where nutritionists in diabetic clinics were trained to deliver mental health care ( 12 ). Remote team care consultations have been utilized when frequent or in-person clinic visits by the psychiatrist were not possible ( 15 ). The Present Study The Philippines has the fastest growing HIV epidemic in the Western Pacific region, with an over 400% increase in incidence from 2012 to 2023 ( 18 ). The country’s Universal Health Care Act, Mental Health Act, and Philippine HIV and AIDS Policy Act ( 19 – 21 ) all aim to strengthen health services in the country to reduce HIV incidence and support comprehensive care of PLHIV. However, our experience working in HIV healthcare systems suggests most local HIV clinics still have poor access to mental health providers and mental health care remains inadequate for PLHIV in the country. This study aimed to explore if the CoCM could be implemented as a way to integrate mental health services in the HIV clinics in the Philippines using HIV counsellors as care managers for mental health. These are individuals who are trained and certified by the Department of Health to provide HIV counselling ( 21 ). Using the Consolidated Framework for Implementation Research (CFIR), we evaluated key stakeholder perspectives on the barriers, facilitators, and acceptability around adaptation and implementation of the CoCM in local HIV clinics in the country. CFIR is a conceptual framework that guides implementation by looking into five main domains: intervention characteristics, outer setting, inner setting, individual characteristics, and processes. ( 22 ) Methods Setting The Philippines is a low-and-middle income country that has a population of 116 million people spread out across 7,641 separate islands in three major geographic areas: Luzon, Visayas and Mindanao; 40% of new HIV cases occur in Luzon ( 23 ). In 2020, 54% lived in urban areas. It is a predominantly Catholic country (79% Roman Catholic) with over 30 ethnicities, the majority of which is Tagalog (26%); 86% are considered non-indigenous people and 7.6% are Indigenous people. There are over 170 languages spoken, with Filipino as the national language. ( 24 – 26 ) Study Design From August of 2021 to March of 2022, we conducted a qualitative study through seven focus group discussions (FGDs) and 18 key informant interviews (KIIs) with stakeholders (policy makers, health care providers, PLHIV) involved in different aspects of HIV and/or mental health care. The study was approved by the Research Institute for Tropical Medicine Institutional Review Board in Muntinlupa, Philippines. Participant Selection The study was conducted in 17 HIV clinics in Luzon (Metro Manila and Calabarzon region), Visayas, and Mindanao (Table 1 ). Table 1 HIV clinics Government Private Non-government Treatment hub (hospital-based HIV clinics) 7 3 - Primary HIV clinic (stand-alone outpatient clinics) 5 - 2 To be eligible to participate in the study, participants had to be over 18 years old, received HIV care (patients) or had professional experience with HIV or mental health (providers) for at least one year, and consented to join the study. We used purposive sampling to select participants from sites with large numbers of PLHIV under care and distributed across the three major geographic target areas. Patients were recruited through referral by HIV counsellors or physicians who shared the study information with patients who then contacted the research team. Other stakeholders including healthcare providers (HIV physicians, counsellors, mental health providers, clinic heads) and policy makers were recruited by the research team through email invitations and were given an option to further discuss the study and review informed consent requirements via phone. Out of the 46 email invitations sent to stakeholders, 33 (72%) agreed to participate. Reasons for not joining included: ( 1 ) declined, ( 2 ) cancelled due to conflict in schedule, and ( 3 ) no reply. Study participants were offered a reimbursement of Php 500 ( $ 10) for time and communications costs for using an online platform. All participants provided informed consent virtually using DocuSign, PDF electronic signature, or by scanning and emailing a signed document file. Data Collection Participants affiliated with clinics – PLHIV patients, counsellors and physicians – were invited to participate in FGDs and were homogeneously grouped according to type of stakeholder. Four FGDs were planned for patients which typically had 5–7 participants per group. However, the third FGD only had 3 participants so we conducted a fourth FGD with patients that had 7 participants. Initially, FGDs were planned for physicians and mental health providers. One FGD was conducted with HIV physicians. However, due to scheduling conflicts and preferences for individual interviews, other HIV physicians and all mental health providers participated in KIIs instead of FGDs. KIIs were also conducted among HIV and mental health policy makers and clinic heads. The number of interviews and FGDs conducted were finalized as data saturation was reached. Separate guides were developed for each of the three groups of stakeholders (policy makers, health care providers, and PLHIV patients) to correspond with their diversity of knowledge and experiences in the fields of HIV and mental health. The interview guides covered three main topics: ( 1 ) HIV and mental health, ( 2 ) current mental health services in HIV clinics, and ( 3 ) attitudes towards the CoCM. We used the CFIR 1.0 ( 22 ) to guide the development of the interview guides to include questions about barriers and facilitators identified from other CoCM studies ( 16 , 17 ) as well as others based on the local context according to the CFIR domains (see supplementary Table 1). Interview guides were pilot tested with one HIV counsellor and one patient to check for clarity and revised accordingly. FGDs and interviews were conducted in both Filipino and English by the study lead (ADL) and a research assistant who are fluent in both languages. Due to the COVID-19-related travel restrictions and safety measures in place at the time of the study, most KIIs and FGDs were conducted via Zoom. Two KIIs were conducted in person at a local hospital. KIIs were between 25–40 minutes with an average of 35 minutes, while FGDs lasted between 60–90 minutes, with an average of 80 minutes. Only the interviewers and participants were present during the data collection. All KIIs and FGDs were audio recorded and saved in a password-protected computer. Audio recordings were transcribed verbatim by a professional transcriber and then the study lead and research assistant listened to the recordings and read the transcriptions to check for accuracy. The initial three transcripts were translated from Filipino into English prior to coding and analysis. Subsequent transcripts were directly coded and analyzed by the study lead and research assistant. Translation to English was done for selected excerpts to support themes described in the results. Data analysis We employed thematic analysis using the CFIR 1.0 domains as themes for data analysis. The study lead and research assistant used inductive coding by developing an initial set of codes after reviewing patterns and topics from the first three transcripts. The codebook was iteratively reviewed and revised based on new KIIs and FGDs that were being conducted. After finalizing the codebook, the lead investigator and research assistant independently double-coded all transcripts. Dedoose software was used to code qualitative data. We then applied a deductive approach to organize the codes according to the CFIR 1.0 domains ( 22 ). Relationships between codes were analyzed as facilitators or barriers that affect the acceptability and feasibility of the CoCM in HIV clinics ( 27 ). Results Participant Demographics A total of 53 stakeholders (n = 20 PLHIV patients, n = 11 HIV counsellors, n = 10 HIV physicians, n = 4 clinic heads, policy makers and mental health providers) participated in seven FGDs and 18 KIIs. Of the 20 PLHIV patients, 19 identified as men and 1 identified as transgender. They had a mean age of 28 years old. The majority were under the care of treatment hubs and were college graduates (Table 2 ). Table 2 Demographic Characteristics of Participants (n = 53) Demographic characteristics PLHIV patients (n = 20) ProfessionalStakeholders (n = 33) Stakeholder PLHIV patients 20 HIV physicians 10 HIV clinic heads 4 HIV counsellors 11 Policy makers 4 Mental health providers 4 Gender Men 19 12 Women 0 19 Transgender 1 2 Age Range 18–59 44 mean 28 1–28 Years consulting in the clinic Range 1–11 Mean 6 Clinic type Primary clinic 6 12 Treatment hub 14 13 Years in service Range 1–28 Mean 8 Educational Attainment Post graduate level 1 College graduate 10 College level 6 Vocational course 2 High school level 1 Training background HIV counselling to testing 11 Training of trainers 6 Case Management Training 9 General practitioners 10 Infectious Disease Specialists 4 Among the other stakeholders (n = 33), the majority (n = 19) were women with a mean age of 44. The professionals had been working in their field of work, either in HIV or mental health, for an average of 8 years. Primary clinics and treatment hubs were equally represented by the HIV providers and clinic heads. Aside from the required basic training for HIV counsellors for HIV testing, most had received further trainings including training of trainers (n = 6) and HIV case management (n = 9). Most of the physicians and clinic heads were general practitioners (n = 10) who were practicing as HIV physicians (Table 2 ). Themes Factors that affected the perceived acceptability and feasibility of the CoCM in HIV clinics spanned the five CFIR domains, as shown in Table 3 . Table 3 CFIR Themes Themes Feasibility Acceptability Barriers Facilitator Intervention Characteristics Adaptability (screening, monitoring, care team) Cost Design Quality Evidence based Outer Settings Patient Needs Collaborations Policies Stigma Inner Settings Available Resources Leader Engagement Tension for Change Structural characteristics Characteristics of Individuals Belief in intervention Individual capacity Individual identification with Organization Other personal attributes Process Planning Executing Evaluation and monitoring Intervention Characteristics (design quality, evidence based, adaptability, cost) Most participants welcomed the idea of the CoCM, as it manages both physical and mental health in the same setting and uses a care team, provided that the team members’ roles and responsibilities are defined. According to an HIV physician, the CoCM can be a good model for less severe cases if HIV providers can assess mental health concerns using screening tools that have been validated among Filipinos and translated in the local language and use evidence-based strategies for care. In a good program, I agree that a psychiatrist or psychologist should be the one to monitor (mental health)… but then let’s go back to the reality that there is inadequate (mental health providers)… I believe psychologists and psychiatrists are expensive. They are not easy to access. So let’s go back to reality, that I agree… if the HIV counsellor or physician can already resolve (mental health concerns), that can be (done), I agree! – PLHIV The inadequate number of psychiatrists in the country compounded by their unequal distribution in rural and urban areas (most are in urban centers) were mentioned as barriers for constructing the CoCM care team. Additionally, more data on the local prevalence of mental health disorders among PLHIV may be needed to get better support in having psychiatrists in HIV clinics, according to policy makers and mental health providers. We have limitations in the number of psychiatrists. Even if it is recommended as a part of the HIV/AIDS core team, not all can comply.- HIV policy maker The cost for a psychiatrist, additional staff and psychotropic medications were also mentioned as potential barriers in implementing the CoCM. Some participants suggested having at least one psychiatrist in the city or province and utilizing teleconsultations to access psychiatrists. In addition, available and affordable psychotropic medications, if possible through the Department of Health or the Philippine Health Insurance, would help implementation according to patients. Some participants shared that factors that may support implementing the CoCM include already having a psychiatrist in HIV clinics, HIV counsellors’ previous experiences with mental health screening tools, and a registry and monitoring process in place where mental health monitoring outcomes can be added. HIV counsellors and patients raised potential concerns by with the mental health screening and monitoring processes that included patients’ time and willingness to participate and a potential breach of confidentiality in registries or during monitoring. Participants recommended incorporating mental health screening in follow-up visits or during times when medications are being refilled and improving patient registries for security and efficiency. One is patient confidentiality and data security….We use open source materials, Microsoft excel, Gmail. So, if we have a tracker or registry, we have to make sure that the access is limited. - HIV physician Outer Setting (patient needs, stigma, policies, collaborations) The CoCM can meet patients’ needs through normalization of mental health consultation and providing more holistic care. Patients may feel better cared for if their HIV providers can manage their mental health concerns. We tried to refer to an outside psychiatrist but […] the client's real concern is "I'm already here at your facility, why would I transfer to someone else?" […] "Why do someone else needs to know about my (HIV) status”. This (CoCM) will really help because we need to enhance our psychosocial services. […] we don't just focus on the virus….- HIV physician Different stakeholders also mentioned that reduced financial concerns, shortened duration of referral to mental health providers, which may sometimes cause loss to follow-up, and the potential to address stigma on both mental health and HIV faced when consulting a psychiatrist were benefits of the CoCM. Actually, it’s the stigma attached to consulting a psychiatrist, that you are really mentally sick… that’s on top of the stigma attached to the HIV diagnosis so the discouragement that a patient would feel to see a psych doctor, just because of that stigma, that’s actually one big factor why it’s very difficult to refer patients to psychiatrists.. - HIV clinic head Participants highlighted several policies that could benefit or challenge implementation. The current Universal Health Care Law and Mental Health Law have already started integrating mental health services in community-based clinics by training primary care physicians using the World Health Organization Mental Health Gap Action Programme (mhGAP) and hiring community psychiatrists. These policies can support the CoCM, according to a mental health provider and policy maker. They’re already training for primary health care physicians (on mental health) because the process is really primary care - primary health care or the universal health care… there’s already a training being done with the mhGap. So I don’t think it's going to be a problem. I think we just need to look what is existing and what can be done.-MH provider However, mental health providers thought that the Counselling Law in the Philippines could be a possible barrier if the policy does not allow HIV counsellors to provide low intensity therapies or administer mental health screening tools. On the other hand, participants stated that the Philippine Health Insurance policy, which includes the Outpatient HIV/AIDS Treatment Package, can support implementation of the CoCM if costs for psychiatrists and psychotropics can be covered. Some participants suggested collaborations, such as within and across hospitals or rehabilitation centers, schools with mental health services, or with volunteer or privately practicing psychiastrists, to have better access to mental health providers. Collaborations between HIV clinics and “access sites” (where the Department of Health distributes psychotropics under the mental health program), and other government agencies that may provide assistance for psychotropic medications were also mentioned. In addition, a policymaker pointed out that collaboration between the governmental HIV and mental health programs is important in planning for the HIV-mental health integrated services. Inner Setting (tension for change, available resources, structural characteristics, leadership) Participants perceived the current mental health services and referral systems – which include support groups, mental health seminars, and referral to HIV counsellors or mental health providers – as inadequate and unclear. They noted that mental health services in HIV clinics need to be strengthened. Patients and HIV providers perceived mental health assessment as inadequate and described assessment as only being done if patients exhibit severe mental health symptoms. Our only measurement is ourselves, the service providers. We don’t have objective [tools], like a checklist when do we refer. If we think we cannot manage anymore, like after 2 or 3 visits, the [patient] is still not okay, then we give up and we refer them. –HIV physician Despite having psychiatrists in some HIV clinics, some HIV and mental health providers believed that training primary care physicians for mental health management would be helpful as psychiatrists are overburdened, resulting in delays in mental health management. The CoCM may help psychiatrists focus more on severe cases. However, most participants also raised concerns about inadequate numbers of HIV clinic doctors and staff, affected by employment status, turnover rate, and redistribution of roles for the COVID-19 response, resulting in higher caseloads and less time per patient as possible barriers in the CoCM. Thus, the CoCM may be more feasible in smaller HIV clinics with lower caseloads. Participants suggested hiring additional staff, strengthening capacity and incentivizing current clinic staff, and improving clinic and documentation processes to be more efficient to address workload. Other identified barriers were a lack of private space for mental health screening and management, which participants deemed important for confidentiality and patients’ comfort, and availability of computers for the patient registry in some HIV clinics. Participants, especially HIV clinic heads and physicians, mentioned lack of leadership support and changes in leadership in HIV and mental health programs as a potential concern, as this may affect allocation of funds and resources, sustainability of programs, or even employee turnover. The mayor is not supportive of the HIV program ---- because of our politics here, ma'am. So it seems that their thoughts about HIV are not stable. – HIV counsellor Characteristics of Individuals (belief in the intervention, individual identification and capacity, passion) Most participants believed that the CoCM can potentially provide more holistic care that may help in early detection of mental health disorders and improve retention to care, treatment adherence, quality of life and patient empowerment. However, some participants thought that the CoCM would only be helpful if sustained. Some patients and HIV providers also expressed preference for a separate mental health program with healthcare providers specific for mental health care. Most providers recognized that HIV counsellors are commonly the first contact of patients in the clinic making them the practical and acceptable option for doing mental health assessment and referral. HIV physicians are sometimes treated as family physicians and long term carers for any medical or psychosocial concerns, giving them the opportunity to do mental health assessment and management. Most participants believed that patients may already have trust, comfort and rapport with their HIV providers which may help with their mental health management. HIV providers expressed a passion for helping patients and a willingness to be trained on mental health and participate in the CoCM for the benefit of patients despite heavy workloads. I already knew that their (HIV counsellors’) passion is really for the patients…. even if this is an additional task, they will really take that additional task wholeheartedly…there is the satisfaction they can get, to a certain degree they helped their patient, I mean with their holistic health. -HIV counsellor However, according to HIV counsellors and physicians, HIV providers need to be prepared for their role in the CoCM, which includes not only the responsibilities, but their own mental health as well to avoid burnout. Some mental health providers also expressed their willingness to be a part of the CoCM and believed other psychiatrists may be also willing. However, an HIV physician and mental health provider still felt that identifying willing psychiatrists could be a challenge. Several participants believed that HIV counsellors’ trainings and capacity for HIV counselling and experience in using screening tools would be helpful for the role of care manager in the CoCM. HIV physicians were thought to already possess basic knowledge about mental health disorders. However, some pointed out that HIV counsellors have diverse training backgrounds, educational levels, knowledge and skills for providing mental health care. Some HIV physicians shared having low confidence, inadequate knowledge and formal training in mental health assessment and management, especially with pharmacotherapy. That’s a good idea. But maybe we still need a lot of training because maybe we’re not doing it habitually. Maybe it’s not our forte anymore, but we are willing to learn. -HIV physician A few HIV providers also mentioned that psychiatrists’ knowledge of HIV concerns and needs may be inadequate, and they may need to learn more about the unique struggles of PLHIV. Process (planning, executing, evaluation and monitoring) Most participants emphasized the need for training both HIV providers and psychiatrists to implement the CoCM. With differences in individual capacity, participants suggested that different levels of mental health training, and HIV training for psychiatrists, would be needed for various providers. Several suggested ways to bolster mental health training included utilizing the World Health Organization mhGAP, incorporating mental health trainings more intensively in HIV trainings, holding separate trainings specifically for mental health issues of PLHIV, or providing mentoring in HIV clinics that have access to a psychiatrist. Ideally, these activities would be free and can be done synchronously or asynchronously for the whole care team to be able to participate. A policymaker expressed that social workers and HIV nurses can also be care managers in the CoCM and other staff with interactions with PLHIV should be considerd for participation in mental health training. Utilizing our (HIV) case manager is a good idea. However, we need to make sure they are properly trained… I don’t think there’s adequate sessions or training for mental health diagnosis and management (in HIV counselling training), so it should be part of the program before. And then there should also be a tool to assess whether they are indeed capable of assessing and managing mental health issues of patients..” – HIV clinic head HIV providers, clinic directors, and policymakers highlighted the need to have a clear protocol, service delivery integration, and proper evaluation and monitoring for the CoCM to be acceptable and feasible. Pilot testing was thought to be important, with some already willing to pilot with their current available resources. Others expressed the need for the CoCM to be piloted in different HIV clinics in the country to assess feasibility and effectiveness and seek funding before they integrate mental health in their HIV clinic. It's just like, formalizing or adapting it. At least like you have an ideal set up, then you have in a resource limited setting, you can start with what is available and then you just improve to reach the ideal.– HIV counselor Other recommendations in planning for the CoCM included adding suicidal risk and substance use assessment, scales for spirituality due to its effect on mental health in the Filipino culture, and incorporating mental health screening as early as HIV testing. A mental health provider suggested that planning should involve consultation with local mental health professionals in the Philippines and other experts, such as anthropologists, sociologists, local tribe leaders, and PLHIVs, accustomed to the local culture. Discussion This study showed stakeholder acceptability of implementing the CoCM in HIV clinics and identified potential barriers and facilitators supporting the feasibility across the five domains of the CFIR. Our findings emphasized the need to improve current mental health services in HIV care and the need to train HIV providers in mental health. Participants identified potential strategies tailored for the local HIV clinics settings that may increase stakeholder buy-in prior to implementation. To our knowledge, this is the first study in the Philippines to explore the use of the CoCM in HIV clinics. For intervention characteristics, participants identified the adaptability and use of evidence-based interventions in the CoCM as facilitators, while implementation cost and the inadequate number of psychiatrists were barriers. Although some partcipants already had previous experiences in using mental health screening tools, some expressed the need to translate it in the local language, which may impact its understandability. In Kosrae, an island state in Micronesia, mental health screening tools for the CoCM were still not clearly understood despite translating to the local language. Study staff therefore adapted the screening to be more conversational ( 28 ). The lack of access to psychiatrists has been identified in other LMICs as well ( 12 , 28 ). Teleconsultation or teleconferencing with the psychiatrist has been shown to be effective in other settings, which was also recommended in this study ( 12 , 15 , 28 ). Implementation costs for health staff, computers or phones, and clinic spaces are also a common barrier mentioned in other CoCM studies, not only in terms of feasibility but also for sustainability despite effective implementation ( 14 ) ( 16 ). The Philippine health insurance budget on HIV and mental health services should be explored as a means to fund the CoCM. In the outer setting, meeting patients’ needs through use of a more holistic care model and local policies, supported the acceptability of CoCM. Collaborations within or across clinics or hospitals to access psychiatrists and psychotropics were identified as facilitators. Participants in this study believed the CoCM can potentially address both HIV and mental health stigma, similar to a finding in the CoCM implemented in primary clinics in northwest England where delivery of mental health care was less stigmatized when incorporated in other clinial management ( 29 ). These findings were in contrast to other studies where mental health stigma, among both patients and providers, low awareness of depression, and lack of trust in primary care providers were identified as barriers in participating in the the CoCM ( 14 , 17 , 28 , 30 ). Policies in the Phillippines that may support the CoCM are the Universal Health Care Act, which aims to provide quality and accessible health care to all Filipinos, and the Mental Health Act, which aims to integrate mental health care in basic health services ( 19 , 20 ). The Guidance and Counselling Act in the Philippines, however, was mentioned as a possible barrier as only registered guidance counsellors are allowed to provide counselling and psychological testing in this law. Hence, it may potentially restrict HIV counsellors, who are not guidance counsellors, from providing low intensity therapies and mental health screening ( 21 , 31 ). In the HIV law, however, HIV counselling can include exploring PLHIV’s personal issues, identifying ways of coping with anxiety and stress, and helping resolve personal, social and psychological problems and difficulties in the context of an HIV diagnosis ( 21 ). Despite the Guidance and Counselling Act, most participants still believed HIV counsellors can be care managers in the CoCM. In the inner setting, participants in this study stressed the need to strengthen mental health services in HIV clinics. However, availability of clinic staff, workload, and lack of support among those leading HIV and mental health services were possible barriers. Similarly, staff shortage and employee turnover increased workload leading to less time for patients. Lack of leadership engagement may affect staff turnover. These are barriers found in other studies from both LMIC and high-income countries ( 12 , 16 , 32 ). In our study, participants identified city mayors as important leaders who need to be engaged, as health programs and services in government or community primary HIV clinics are under their leadership. Similarly, Ngo et al. emphasized the importance of engaging political, administrative, health and mental health leaders for effectively implementing the CoCM in Vietnam ( 14 ). Participants acknowledged that characteristics of individuals, including HIV providers’ primary role in HIV care and patients’ trust in providers, passion in delivering high quality care for PLHIV, and current knowledge and skills in HIV counselling supported acceptability. However, lack of mental health knowledge among HIV providers was emphasized as a barrier, a common finding in other CoCM studies ( 16 , 17 , 30 , 32 ). Conducting a baseline assessment of HIV providers’ skills and core competencies in mental health management can help assess their self-efficacy and prepare for their roles in the CoCM. The study in Kosrae found that psychiatrists who developed a deeper understanding of the local culture gave more appropriate mental health recommendations to the care team ( 28 ). HIV providers in this study felt that some psychiatrists may need to increase their knowledge about HIV, which could help deliver more tailored care. Providers’ expressed passion for caring for PLHIV may be similar to the CoCM for older people in China where the care team members’ care for the elderly supported their willingness to participate in the CoCM and was thought to be a factor in its effectiveness in reducing depressive symptoms. ( 33 ). In contrast, other studies showed resistance from clinic staff and a lack of willingness to change due to the additional responsibilities among an already overburdened staff ( 14 , 16 ). In Nepal and Vietnam, observing improvement in patients’ outcomes and targeting the values of providers by emphasizing their roles as change agents improved acceptability and participation in the CoCM ( 14 , 15 ). Importance of having trust in providers has also influenced the acceptability of the CoCM in HIV clinics in the US and in China, with patients being more comfortable and truthful with the care team when trust is present ( 33 , 34 ). It is important to note, however, that some PLHIV and HIV providers in this study still expressed a preference for separate physical and mental health care. In a primary care clinic in England, the authors found that integrating mental health in primary care can undermine mental health management, especially if the mental health condition is explored in the context of patients’ medical condition, which may be given higher priority ( 29 ). In the context of this study, not all mental health conditions may be related to a person’s HIV status. These preferences may impact the acceptability and success of implementing the CoCM and may inform the design of a more flexible model of care, such as access to specialists or designating clinic staff specific for delivery of mental health care ( 29 ). Recommendations for implementing the CoCM included training HIV providers, establishing clear processes, pilot testing, and tailoring implementation to the local setting and culture. Adequate training of both HIV and mental health providers is crucial and has enhanced motivation to participate in the CoCM ( 15 ). In Vietnam and India, other personnel - including nurses, village health collaborators and health workers, social workers, and even nutritioninsts - were trained for the role of care managers ( 12 , 14 , 15 ). This broadened approach is congruent with the findings in this study that recommended that all clinic staff with any patient interaction should be trained for providing mental health care. Unclear processes and role confusion by the care team physicians and counsellors have been identified as barriers in implementing the care team approach ( 15 , 16 ). Hence, establishing a clear work flow, care team roles, and standardizing the implementation process are necessary for the the CoCM to be acceptable. However, when a US clinic implemented the CoCM, the time it took to develop the tools and processes prior to implementation may have had a negative effect by slowing down the implementation process. In other studies, a trial and error approach has helped by testing a process and making adjustments after ( 16 ). Pilot testing the CoCM in HIV clinics in the Philippines would help tailor it to the available resources and local cultural context, and assess its effectiveness to increase stakeholder buy-in and support future funding, as seen in other studies ( 14 , 28 , 35 ). Limitations This study has several limitations with regard to generalizability in HIV clinics in the Philippines. Despite including providers and patients from different types of HIV clinics (private, government, hospital-based and stand-alone clinics), organizational settings and culture may still differ by individual clinic, which may correspond to differences in barriers and facilitators. Participants interested in joining the study may have had heightened awareness about the importance of mental health, which may have influenced their perceived acceptability. Women living with HIV, who may have different perspectives, were also underrepresented in this study. Lastly, as this is a formative pre-implementation study, acceptability, barriers and facilitators may differ in the implementation phase. Conclusion Participants perceived the CoCM to integrate mental health in HIV care using HIV counsellors as care managers in HIV clinics in the Philippines as acceptable. Perceived barriers included inadequate numbers of psychiatrists in the country, an overburdened and understaffed workforce in HIV clinics, and inadequate mental health knowledge among HIV providers. Facilitators and recommendations included training HIV and mental health providers, intra- and inter-clinic collaborations to facilitate better access to psychiatrists, proper planning with standardized processes, and pilot testing to implement the CoCM in an acceptable and feasible way in HIV clinics in the Philippines. Abbreviations CFIR Consolidated Framework for Implementation Research CoCM Collaborative Care Model FGD Focus group discussions KII Key informant interviews LMIC low-and-middle income countries mhGAP Mental Health Gap Action Programme PLHIV Person living with HIV Declarations Ethics approval and consent to participate This study has been approved by the Research Institute for Tropical Medicine Institutional review board with IRB protocol number 2020-41. All participants in this study signed an informed consent and all methods done were in accordance to the approved IRB protocol. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported through a grant from amfAR, The Foundation for AIDS Research, with support from the US National Institutes of Health’s Fogarty International Center and the National Institute of Mental Health (CHIMERA; D43TW011302). This work is solely the responsibility of the authors and does not necessarily represent the official views of any of the institutions mentioned above. Authors’ contributions ADL is the principal investigator and was involved in the conceptualization and planning of the study and led the implementation, data analysis and writing of the manuscript. JM was involved in reviewing the data analysis, writing, design and finalization of the manuscript. AS was involved in conceptualization and planning of the study, reviewed and revised the final manuscript. RD was involved in the conceptualization and planning of the study. MM was involved in the conceptualization of the study and review of the manuscript. RT was involved in the implementation of the study and data analysis as the research assistant of the principal investigator. TD was involved in the conceptualization of the study and assisted in data management. Acknowledgements We want to express our gratitude to TREAT Asia, Columbia University and the CHIMERA training program for their support in this study. Authors’ information Research Institute for Tropical Medicine, Manila, Philippines Anna Maureen Dungca-Lorilla MD Rossana Ditangco MD Timothy John Dizon MD Roxanne Emily Tanuecoz RPm Columbia University, Department of Psychiatry, New York, USA Jennifer Mootz PhD TREAT Asia, amfAR- The Foundation for AIDS Research, Bangkok, Thailand Annette Sohn MD PhD Ateneo De Manila University, Philippines Maria Isabel Melgar PhD References Soliman B, Reyes ME. Mental Health Status of Filipino Youth Living with Human Immunodeficiency Virus. North American Journal of Psychology. 2019;21:465-75. Gauiran DT, Samala K, Lim J, Guzman M. Measurement of Anxiety and Depression Among HIV Patients Seen in the Philippine General Hospital Using the Hospital Anxiety and Depression Scale - Pilipino Version (HADS-P). Acta medica Philippina. 2018;52:40-52. Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158(5):725-30. Remien RH, Stirratt MJ, Nguyen N, Robbins RN, Pala AN, Mellins CA. Mental health and HIV/AIDS: the need for an integrated response. AIDS. 2019;33(9):1411-20. World Health Organization. Integration of Mental health and HIV Interventions 2022 [Available from: https://www.who.int/publications/i/item/9789240043176. American Psychiatric Association, Academy of Psychosomatic Medicine. Dissemination of Integrated Care Within Adult Primary Care Settings The Collaborative Care Model. 2016. Advancing Integrated Mental Health Solutions (AIMS) Center Washington University. Collaborative Care [Available from: https://aims.uw.edu/collaborative-care. Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illnesses. N Engl J Med. 2010;363(27):2611-20. Huang Y, Wei X, Wu T, Chen R, Guo A. Collaborative care for patients with depression and diabetes mellitus: a systematic review and meta-analysis. BMC Psychiatry. 2013;13(1):260. Pyne JM, Fortney JC, Curran GM, Tripathi S, Atkinson JH, Kilbourne AM, et al. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Arch Intern Med. 2011;171(1):23-31. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314-21. Acharya B, Ekstrand M, Rimal P, Ali MK, Swar S, Srinivasan K, et al. Collaborative Care for Mental Health in Low- and Middle-Income Countries: A WHO Health Systems Framework Assessment of Three Programs. Psychiatr Serv. 2017;68(9):870-2. Petersen I, Bhana A, Fairall LR, Selohilwe O, Kathree T, Baron EC, et al. Evaluation of a collaborative care model for integrated primary care of common mental disorders comorbid with chronic conditions in South Africa. BMC Psychiatry. 2019;19(1):107. Ngo VK, Weiss B, Lam T, Dang T, Nguyen T, Nguyen MH. The Vietnam Multicomponent Collaborative Care for Depression Program: Development of Depression Care for Low- and Middle-Income Nations. J Cogn Psychother. 2014;28(3):156-67. Rimal P, Choudhury N, Agrawal P, Basnet M, Bohara B, Citrin D, et al. Collaborative care model for depression in rural Nepal: a mixed-methods implementation research study. BMJ Open. 2021;11(8):e048481. Eghaneyan BH, Sanchez K, Mitschke DB. Implementation of a collaborative care model for the treatment of depression and anxiety in a community health center: results from a qualitative case study. J Multidiscip Healthc. 2014;7:503-13. Sanchez K. Collaborative care in real-world settings: Barriers and opportunities for sustainability. Patient Preference and Adherence. 2017/01/05;Volume 11:71-4. Gangcuangco LMA, Eustaquio PC. The State of the HIV Epidemic in the Philippines: Progress and Challenges in 2023. Trop Med Infect Dis. 2023;8(5). Mental Health Act, Senate and House of Representatives of the Philippines(2017). Universal Health Care Act, Senate and House of Representatives of the Philippines(2018). Philippine HIV and AIDS Policy Act, Senate and House of Representatives of the Philippines(2018). The Consolidated Framework for Implementation Research 2020 [Available from: www.cfirguide.org. Department of Health Epidemiology Bureau. HIV/AIDS & ART Registry of the Philippines. May 2023. Ethnic Groups of the Philippines. Languages in the Philippines [Available from: http://www.ethnicgroupsphilippines.com/languages-in-the-philippines/. Ethnicity in the Philippines (2020 Census of Population and Housing): Philippine Statistics Authority; 2023 [Available from: https://psa.gov.ph/content/ethnicity-philippines-2020-census-population-and-housing. Religious Affiliation in the Philippines (2020 Census of Population and Housing): Philippine Statistics Authority; 2023 [Available from: https://psa.gov.ph/content/religious-affiliation-philippines-2020-census-population-and-housing. Wood E, Ohlsen S, Ricketts T. What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review. J Affect Disord. 2017;214:26-43. Haack SA, Rehuher D, Ghiasuddin A, Kiyota T, Alik TP. Implementation of an Adapted Collaborative Care Model. Psychiatr Serv. 2022;73(10):1186-9. Knowles SE, Chew-Graham C, Adeyemi I, Coupe N, Coventry PA. Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model. BMC Fam Pract. 2015;16:32. Fu E, Carroll AJ, Rosenthal LJ, Rado J, Burnett-Zeigler I, Jordan N, et al. Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety. J Gen Intern Med. 2023;38(2):366-74. Tuason MT, Alvarez, Margaret, Stanton Bridget. The Counseling Profession in the Philippines. Australian Counselling Research Journal. 2021. Andrea Marie AB, Merlita VC, Joseph Gedeoni CV. Implementation, Best Practices, and Challenges in Mental Health Strategies among Local Government Units in the Province of Negros Occidental, Philippines. Philippine Social Science Journal. 2022;5(2). Li LW, Xue J, Conwell Y, Yang Q, Chen S. Implementing collaborative care for older people with comorbid hypertension and depression in rural China. Int Psychogeriatr. 2020;32(12):1457-65. Fuller SM, Koester KA, Erguera XA, Wilde Botta E, von Beetzen F, Steward WT, et al. The collaborative care model for HIV and depression: Patient perspectives and experiences from a safety-net clinic in the United States. SAGE Open Med. 2019;7:2050312119842249. Whitfield J, Owens S, Bhat A, Felker B, Jewell T, Chwastiak L. Successful ingredients of effective Collaborative Care programs in low- and middle-income countries: A rapid review. Cambridge Prisms: Global Mental Health. 2023;10:e11. Additional Declarations No competing interests reported. Supplementary Files supplementary.tableinterviewGuides7.2024.docx Cite Share Download PDF Status: Published Journal Publication published 08 May, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 25 Jul, 2024 Editor assigned by journal 25 Jul, 2024 Submission checks completed at journal 23 Jul, 2024 First submitted to journal 22 Jul, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4780343","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":331659797,"identity":"0ca15c6f-3428-4cf2-8da0-816bd98767a0","order_by":0,"name":"Anna Maureen Dungca-Lorilla","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABCklEQVRIiWNgGAWjYDADPiA+8KCAQY6BGS7Gg18LG0hLggGDMQMzXA8RWhiAWhIbGAho0W0/Y/bhQ8UdBjb23odAW+zSt7fzH93A8MsmsUG69wA2LWZncoxnzjjzjIGN57gBUEty7pzDzGw3GPvSEhtkziVg1XIgx5iZt+0wA5tEGsgvzLkzmEFaeg4bM0jkGGDVcv6NMfPff3At9ekSBLXcANrC2ADXcjgBrIXhx2E53FqeFTP2HDvMw8ZzDKTluCHQYWY3EhvS5NhkzuBwWPJmhh81h+X42duYgUFXLS/Bf/DZjQ9/bHj4pXuwaoEBtChIbAPGlAQ+DZjgDxCTqGUUjIJRMAqGLQAAn/NZ/uMeIBsAAAAASUVORK5CYII=","orcid":"","institution":"Research Institute for Tropical Medicine","correspondingAuthor":true,"prefix":"","firstName":"Anna","middleName":"Maureen","lastName":"Dungca-Lorilla","suffix":""},{"id":331659798,"identity":"0704df15-a26a-4a36-9b5a-9c08a4d10e2d","order_by":1,"name":"Jennifer Mootz","email":"","orcid":"","institution":"Columbia University","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"","lastName":"Mootz","suffix":""},{"id":331659799,"identity":"2f250c48-caf3-4ef4-83f6-0606f4f51921","order_by":2,"name":"Maria Isabel Melgar","email":"","orcid":"","institution":"Ateneo De Manila University","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"Isabel","lastName":"Melgar","suffix":""},{"id":331659800,"identity":"27525c17-a893-44a6-8a44-b1cf2ca694d6","order_by":3,"name":"Roxanne Emily Tanuecoz RPm","email":"","orcid":"","institution":"Research Institute for Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Roxanne","middleName":"Emily Tanuecoz","lastName":"RPm","suffix":""},{"id":331659801,"identity":"01be5711-40d7-4f68-b6e2-054be8848f46","order_by":4,"name":"Timothy John Dizon","email":"","orcid":"","institution":"Research Institute for Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Timothy","middleName":"John","lastName":"Dizon","suffix":""},{"id":331659802,"identity":"ce5b7ba8-ee69-4b4d-8ebe-b3556aa3575b","order_by":5,"name":"Annette H. Sohn","email":"","orcid":"","institution":"TREAT Asia, amfAR- The Foundation for AIDS Research","correspondingAuthor":false,"prefix":"","firstName":"Annette","middleName":"H.","lastName":"Sohn","suffix":""},{"id":331659809,"identity":"3ead85da-2d95-40b3-931a-33ffe065b0d3","order_by":6,"name":"Rossana Ditangco","email":"","orcid":"","institution":"Research Institute for Tropical Medicine","correspondingAuthor":false,"prefix":"","firstName":"Rossana","middleName":"","lastName":"Ditangco","suffix":""}],"badges":[],"createdAt":"2024-07-22 08:36:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4780343/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4780343/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-12703-y","type":"published","date":"2025-05-08T15:57:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":82537523,"identity":"d2fbc9f0-6d3a-437d-adc1-a75db6c9aec6","added_by":"auto","created_at":"2025-05-12 16:07:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":947480,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4780343/v1/e0c5f5d8-710b-4cdb-bd28-e06176ae57b6.pdf"},{"id":62793536,"identity":"c9f26dcb-71b3-456f-b23a-3b851a9d3cfd","added_by":"auto","created_at":"2024-08-19 14:41:16","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":18703,"visible":true,"origin":"","legend":"","description":"","filename":"supplementary.tableinterviewGuides7.2024.docx","url":"https://assets-eu.researchsquare.com/files/rs-4780343/v1/7628b054d563b13fb9447254.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Acceptability and Feasibility of a Task-Shifted Collaborative Care Model for Depression and Anxiety in Primary HIV Clinics in the Philippines: A Qualitative Inquiry","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePeople living with HIV (PLHIV) have at least double the prevalence of mental health disorders than the general population, with depression and anxiety being the most common diagnoses (\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). If left undiagnosed and untreated, these mental health conditions may have a negative impact on the HIV care continuum at screening and linkage to care, as well as on treatment adherence and overall quality of life (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Bringing aspects of mental health care delivery into HIV care has been recommended to address the mental health needs of PLHIV and increase access to mental health care (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe Collaborative Care Model (CoCM) is an evidence-based approach to integrating mental health services in primary care settings through a task-sharing strategy utilizing non-specialized providers. Based on large-scale adaptations mostly done in high-income settings, a report by the American Psychiatric Association and Academy of Psychosomatic Medicine summarized the four essential components of the CoCM (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). First, it is \u003cem\u003eteam-driven\u003c/em\u003e, defined as care led by a primary care physician with support from a care manager who is a behavioral health provider (e.g., social worker, licensed counsellor, nurses with mental health training) and a psychiatrist consultant. Care managers provide psychoeducation, brief behavioral interventions, or referral to specialist care. A psychiatrist consultant provides guidance to the team and is available to treat more complicated cases. Second, the CoCM is \u003cem\u003epopulation-focused\u003c/em\u003e, meaning a patient registry is shared among the members of the care team to monitor responses to treatment and track patients who need more focused care. Third, the CoCM is \u003cem\u003emeasurement-guided\u003c/em\u003e through the use of standardized mental health symptom rating scales to guide assessment, formulate treatment plans, and enact monitoring. Finally, the CoCM provides \u003cem\u003eevidence-based\u003c/em\u003e care, such as established psychotherapies and primary care provider-prescribed pharmacotherapy (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe CoCM has effectively reduced the clinical burden of common mental health disorders, demonstrating short- and long-term improvements in depression as compared to the standard of care (\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The approach has been adapted and studied in diverse primary care settings to manage HIV and other chronic conditions, such as diabetes and coronary heart disease, in both high-income and low-and-middle income countries (LMIC) like India, Nepal, South Africa, and Vietnam (\u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Barriers in implementing this model have included provider-level challenges (e.g., lack of knowledge and skills and engagement), patient-level issues (e.g., engagement and mental health stigma), organizational limitations (e.g., work flow issues, standardization of processes, workforce shortages), and insufficient financial resources (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecommendations to support successful implementation have entailed multi-disciplinary linkages across service sectors, stakeholder engagement, and strong leadership. In some settings, health workers from other disciplines were trained as care managers, such as in India where nutritionists in diabetic clinics were trained to deliver mental health care (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Remote team care consultations have been utilized when frequent or in-person clinic visits by the psychiatrist were not possible (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eThe Present Study\u003c/h2\u003e \u003cp\u003eThe Philippines has the fastest growing HIV epidemic in the Western Pacific region, with an over 400% increase in incidence from 2012 to 2023 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The country\u0026rsquo;s Universal Health Care Act, Mental Health Act, and Philippine HIV and AIDS Policy Act (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) all aim to strengthen health services in the country to reduce HIV incidence and support comprehensive care of PLHIV. However, our experience working in HIV healthcare systems suggests most local HIV clinics still have poor access to mental health providers and mental health care remains inadequate for PLHIV in the country.\u003c/p\u003e \u003cp\u003eThis study aimed to explore if the CoCM could be implemented as a way to integrate mental health services in the HIV clinics in the Philippines using HIV counsellors as care managers for mental health. These are individuals who are trained and certified by the Department of Health to provide HIV counselling (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Using the Consolidated Framework for Implementation Research (CFIR), we evaluated key stakeholder perspectives on the barriers, facilitators, and acceptability around adaptation and implementation of the CoCM in local HIV clinics in the country. CFIR is a conceptual framework that guides implementation by looking into five main domains: intervention characteristics, outer setting, inner setting, individual characteristics, and processes. (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThe Philippines is a low-and-middle income country that has a population of 116\u0026nbsp;million people spread out across 7,641 separate islands in three major geographic areas: Luzon, Visayas and Mindanao; 40% of new HIV cases occur in Luzon (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). In 2020, 54% lived in urban areas. It is a predominantly Catholic country (79% Roman Catholic) with over 30 ethnicities, the majority of which is Tagalog (26%); 86% are considered non-indigenous people and 7.6% are Indigenous people. There are over 170 languages spoken, with Filipino as the national language. (\u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eFrom August of 2021 to March of 2022, we conducted a qualitative study through seven focus group discussions (FGDs) and 18 key informant interviews (KIIs) with stakeholders (policy makers, health care providers, PLHIV) involved in different aspects of HIV and/or mental health care. The study was approved by the Research Institute for Tropical Medicine Institutional Review Board in Muntinlupa, Philippines.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Selection\u003c/h2\u003e \u003cp\u003eThe study was conducted in 17 HIV clinics in Luzon (Metro Manila and Calabarzon region), Visayas, and Mindanao (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHIV clinics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGovernment\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNon-government\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment hub\u003c/p\u003e \u003cp\u003e(hospital-based HIV clinics)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary HIV clinic\u003c/p\u003e \u003cp\u003e(stand-alone outpatient clinics)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTo be eligible to participate in the study, participants had to be over 18 years old, received HIV care (patients) or had professional experience with HIV or mental health (providers) for at least one year, and consented to join the study. We used purposive sampling to select participants from sites with large numbers of PLHIV under care and distributed across the three major geographic target areas. Patients were recruited through referral by HIV counsellors or physicians who shared the study information with patients who then contacted the research team. Other stakeholders including healthcare providers (HIV physicians, counsellors, mental health providers, clinic heads) and policy makers were recruited by the research team through email invitations and were given an option to further discuss the study and review informed consent requirements via phone. Out of the 46 email invitations sent to stakeholders, 33 (72%) agreed to participate. Reasons for not joining included: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) declined, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) cancelled due to conflict in schedule, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) no reply.\u003c/p\u003e \u003cp\u003eStudy participants were offered a reimbursement of Php 500 (\u003cspan\u003e$\u003c/span\u003e10) for time and communications costs for using an online platform. All participants provided informed consent virtually using DocuSign, PDF electronic signature, or by scanning and emailing a signed document file.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eParticipants affiliated with clinics \u0026ndash; PLHIV patients, counsellors and physicians \u0026ndash; were invited to participate in FGDs and were homogeneously grouped according to type of stakeholder. Four FGDs were planned for patients which typically had 5\u0026ndash;7 participants per group. However, the third FGD only had 3 participants so we conducted a fourth FGD with patients that had 7 participants. Initially, FGDs were planned for physicians and mental health providers. One FGD was conducted with HIV physicians. However, due to scheduling conflicts and preferences for individual interviews, other HIV physicians and all mental health providers participated in KIIs instead of FGDs. KIIs were also conducted among HIV and mental health policy makers and clinic heads. The number of interviews and FGDs conducted were finalized as data saturation was reached.\u003c/p\u003e \u003cp\u003eSeparate guides were developed for each of the three groups of stakeholders (policy makers, health care providers, and PLHIV patients) to correspond with their diversity of knowledge and experiences in the fields of HIV and mental health. The interview guides covered three main topics: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) HIV and mental health, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) current mental health services in HIV clinics, and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) attitudes towards the CoCM. We used the CFIR 1.0 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) to guide the development of the interview guides to include questions about barriers and facilitators identified from other CoCM studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) as well as others based on the local context according to the CFIR domains (see supplementary Table\u0026nbsp;1). Interview guides were pilot tested with one HIV counsellor and one patient to check for clarity and revised accordingly.\u003c/p\u003e \u003cp\u003eFGDs and interviews were conducted in both Filipino and English by the study lead (ADL) and a research assistant who are fluent in both languages. Due to the COVID-19-related travel restrictions and safety measures in place at the time of the study, most KIIs and FGDs were conducted via Zoom. Two KIIs were conducted in person at a local hospital. KIIs were between 25\u0026ndash;40 minutes with an average of 35 minutes, while FGDs lasted between 60\u0026ndash;90 minutes, with an average of 80 minutes. Only the interviewers and participants were present during the data collection. All KIIs and FGDs were audio recorded and saved in a password-protected computer.\u003c/p\u003e \u003cp\u003eAudio recordings were transcribed verbatim by a professional transcriber and then the study lead and research assistant listened to the recordings and read the transcriptions to check for accuracy. The initial three transcripts were translated from Filipino into English prior to coding and analysis. Subsequent transcripts were directly coded and analyzed by the study lead and research assistant. Translation to English was done for selected excerpts to support themes described in the results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eWe employed thematic analysis using the CFIR 1.0 domains as themes for data analysis. The study lead and research assistant used inductive coding by developing an initial set of codes after reviewing patterns and topics from the first three transcripts. The codebook was iteratively reviewed and revised based on new KIIs and FGDs that were being conducted. After finalizing the codebook, the lead investigator and research assistant independently double-coded all transcripts. Dedoose software was used to code qualitative data.\u003c/p\u003e \u003cp\u003eWe then applied a deductive approach to organize the codes according to the CFIR 1.0 domains (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Relationships between codes were analyzed as facilitators or barriers that affect the acceptability and feasibility of the CoCM in HIV clinics (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eParticipant Demographics\u003c/h2\u003e \u003cp\u003eA total of 53 stakeholders (n\u0026thinsp;=\u0026thinsp;20 PLHIV patients, n\u0026thinsp;=\u0026thinsp;11 HIV counsellors, n\u0026thinsp;=\u0026thinsp;10 HIV physicians, n\u0026thinsp;=\u0026thinsp;4 clinic heads, policy makers and mental health providers) participated in seven FGDs and 18 KIIs. Of the 20 PLHIV patients, 19 identified as men and 1 identified as transgender. They had a mean age of 28 years old. The majority were under the care of treatment hubs and were college graduates (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic Characteristics of Participants (n\u0026thinsp;=\u0026thinsp;53)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eDemographic characteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePLHIV patients\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;20)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProfessionalStakeholders (n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eStakeholder\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePLHIV patients\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIV physicians\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIV clinic heads\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIV counsellors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePolicy makers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMental health providers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWomen\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTransgender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u0026ndash;59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003emean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYears consulting in the clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026ndash;11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eClinic type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTreatment hub\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eYears in service\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;28\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eEducational Attainment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePost graduate level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eVocational course\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh school level\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eTraining background\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHIV counselling to testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraining of trainers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCase Management Training\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGeneral practitioners\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInfectious Disease Specialists\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAmong the other stakeholders (n\u0026thinsp;=\u0026thinsp;33), the majority (n\u0026thinsp;=\u0026thinsp;19) were women with a mean age of 44. The professionals had been working in their field of work, either in HIV or mental health, for an average of 8 years. Primary clinics and treatment hubs were equally represented by the HIV providers and clinic heads. Aside from the required basic training for HIV counsellors for HIV testing, most had received further trainings including training of trainers (n\u0026thinsp;=\u0026thinsp;6) and HIV case management (n\u0026thinsp;=\u0026thinsp;9). Most of the physicians and clinic heads were general practitioners (n\u0026thinsp;=\u0026thinsp;10) who were practicing as HIV physicians (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eThemes\u003c/h2\u003e \u003cp\u003eFactors that affected the perceived acceptability and feasibility of the CoCM in HIV clinics spanned the five CFIR domains, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCFIR Themes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFeasibility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAcceptability\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBarriers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFacilitator\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eIntervention Characteristics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eAdaptability (screening, monitoring, care team)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCost\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDesign Quality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEvidence based\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eOuter Settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePatient Needs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCollaborations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003ePolicies\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStigma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eInner Settings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eAvailable Resources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLeader Engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eTension for Change\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eStructural characteristics\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eCharacteristics of Individuals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBelief in intervention\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eIndividual capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eIndividual identification with Organization\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eOther personal attributes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eProcess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003ePlanning\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eExecuting\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eEvaluation and monitoring\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eIntervention Characteristics\u003c/b\u003e \u003cb\u003e(design quality, evidence based, adaptability, cost)\u003c/b\u003e\u003c/p\u003e \u003cp\u003eMost participants welcomed the idea of the CoCM, as it manages both physical and mental health in the same setting and uses a care team, provided that the team members\u0026rsquo; roles and responsibilities are defined. According to an HIV physician, the CoCM can be a good model for less severe cases if HIV providers can assess mental health concerns using screening tools that have been validated among Filipinos and translated in the local language and use evidence-based strategies for care.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eIn a good program, I agree that a psychiatrist or psychologist should be the one to monitor (mental health)\u0026hellip; but then let\u0026rsquo;s go back to the reality that there is inadequate (mental health providers)\u0026hellip; I believe psychologists and psychiatrists are expensive. They are not easy to access. So let\u0026rsquo;s go back to reality, that I agree\u0026hellip; if the HIV counsellor or physician can already resolve (mental health concerns), that can be (done), I agree! \u0026ndash; PLHIV\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe inadequate number of psychiatrists in the country compounded by their unequal distribution in rural and urban areas (most are in urban centers) were mentioned as barriers for constructing the CoCM care team. Additionally, more data on the local prevalence of mental health disorders among PLHIV may be needed to get better support in having psychiatrists in HIV clinics, according to policy makers and mental health providers.\u003c/p\u003e\u003cp\u003e\u003cem\u003eWe have limitations in the number of psychiatrists. Even if it is recommended as a part of the HIV/AIDS core team, not all can comply.- HIV policy maker\u003c/em\u003e\u003c/p\u003e\u003cp\u003eThe cost for a psychiatrist, additional staff and psychotropic medications were also mentioned as potential barriers in implementing the CoCM. Some participants suggested having at least one psychiatrist in the city or province and utilizing teleconsultations to access psychiatrists. In addition, available and affordable psychotropic medications, if possible through the Department of Health or the Philippine Health Insurance, would help implementation according to patients.\u003c/p\u003e\u003cp\u003eSome participants shared that factors that may support implementing the CoCM include already having a psychiatrist in HIV clinics, HIV counsellors\u0026rsquo; previous experiences with mental health screening tools, and a registry and monitoring process in place where mental health monitoring outcomes can be added. HIV counsellors and patients raised potential concerns by with the mental health screening and monitoring processes that included patients\u0026rsquo; time and willingness to participate and a potential breach of confidentiality in registries or during monitoring. Participants recommended incorporating mental health screening in follow-up visits or during times when medications are being refilled and improving patient registries for security and efficiency.\u003c/p\u003e\u003cp\u003e\u003cem\u003eOne is patient confidentiality and data security\u0026hellip;.We use open source materials, Microsoft excel, Gmail. So, if we have a tracker or registry, we have to make sure that the access is limited. - HIV physician\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOuter Setting\u003c/b\u003e\u003cb\u003e(patient needs, stigma, policies, collaborations)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe CoCM can meet patients\u0026rsquo; needs through normalization of mental health consultation and providing more holistic care. Patients may feel better cared for if their HIV providers can manage their mental health concerns.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eWe tried to refer to an outside psychiatrist but [\u0026hellip;] the client's real concern is \"I'm already here at your facility, why would I transfer to someone else?\" [\u0026hellip;] \"Why do someone else needs to know about my (HIV) status\u0026rdquo;. This (CoCM) will really help because we need to enhance our psychosocial services. [\u0026hellip;] we don't just focus on the virus\u0026hellip;.- HIV physician\u003c/em\u003e \u003c/p\u003e \u003cp\u003eDifferent stakeholders also mentioned that reduced financial concerns, shortened duration of referral to mental health providers, which may sometimes cause loss to follow-up, and the potential to address stigma on both mental health and HIV faced when consulting a psychiatrist were benefits of the CoCM.\u003c/p\u003e \u003cp\u003e\u003cem\u003eActually, it\u0026rsquo;s the stigma attached to consulting a psychiatrist, that you are really mentally sick\u0026hellip; that\u0026rsquo;s on top of the stigma attached to the HIV diagnosis so the discouragement that a patient would feel to see a psych doctor, just because of that stigma, that\u0026rsquo;s actually one big factor why it\u0026rsquo;s very difficult to refer patients to psychiatrists.. - HIV clinic head\u003c/em\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eParticipants highlighted several policies that could benefit or challenge implementation. The current Universal Health Care Law and Mental Health Law have already started integrating mental health services in community-based clinics by training primary care physicians using the World Health Organization Mental Health Gap Action Programme (mhGAP) and hiring community psychiatrists. These policies can support the CoCM, according to a mental health provider and policy maker.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThey\u0026rsquo;re already training for primary health care physicians (on mental health) because the process is really primary care - primary health care or the universal health care\u0026hellip; there\u0026rsquo;s already a training being done with the mhGap. So I don\u0026rsquo;t think it's going to be a problem. I think we just need to look what is existing and what can be done.-MH provider\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHowever, mental health providers thought that the Counselling Law in the Philippines could be a possible barrier if the policy does not allow HIV counsellors to provide low intensity therapies or administer mental health screening tools. On the other hand, participants stated that the Philippine Health Insurance policy, which includes the Outpatient HIV/AIDS Treatment Package, can support implementation of the CoCM if costs for psychiatrists and psychotropics can be covered.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants suggested collaborations, such as within and across hospitals or rehabilitation centers, schools with mental health services, or with volunteer or privately practicing psychiastrists, to have better access to mental health providers. Collaborations between HIV clinics and \u0026ldquo;access sites\u0026rdquo; (where the Department of Health distributes psychotropics under the mental health program), and other government agencies that may provide assistance for psychotropic medications were also mentioned. In addition, a policymaker pointed out that collaboration between the governmental HIV and mental health programs is important in planning for the HIV-mental health integrated services.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cb\u003eInner Setting\u003c/b\u003e \u003cb\u003e(tension for change, available resources, structural characteristics, leadership)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants perceived the current mental health services and referral systems \u0026ndash; which include support groups, mental health seminars, and referral to HIV counsellors or mental health providers \u0026ndash; as inadequate and unclear. They noted that mental health services in HIV clinics need to be strengthened. Patients and HIV providers perceived mental health assessment as inadequate and described assessment as only being done if patients exhibit severe mental health symptoms.\u003c/p\u003e\u003cp\u003e \u003cem\u003eOur only measurement is ourselves, the service providers. We don\u0026rsquo;t have objective [tools], like a checklist when do we refer. If we think we cannot manage anymore, like after 2 or 3 visits, the [patient] is still not okay, then we give up and we refer them. \u0026ndash;HIV physician\u003c/em\u003e \u003c/p\u003e\u003cp\u003eDespite having psychiatrists in some HIV clinics, some HIV and mental health providers believed that training primary care physicians for mental health management would be helpful as psychiatrists are overburdened, resulting in delays in mental health management. The CoCM may help psychiatrists focus more on severe cases. However, most participants also raised concerns about inadequate numbers of HIV clinic doctors and staff, affected by employment status, turnover rate, and redistribution of roles for the COVID-19 response, resulting in higher caseloads and less time per patient as possible barriers in the CoCM. Thus, the CoCM may be more feasible in smaller HIV clinics with lower caseloads. Participants suggested hiring additional staff, strengthening capacity and incentivizing current clinic staff, and improving clinic and documentation processes to be more efficient to address workload. Other identified barriers were a lack of private space for mental health screening and management, which participants deemed important for confidentiality and patients\u0026rsquo; comfort, and availability of computers for the patient registry in some HIV clinics.\u003c/p\u003e\u003cp\u003eParticipants, especially HIV clinic heads and physicians, mentioned lack of leadership support and changes in leadership in HIV and mental health programs as a potential concern, as this may affect allocation of funds and resources, sustainability of programs, or even employee turnover.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe mayor is not supportive of the HIV program ---- because of our politics here, ma'am. So it seems that their thoughts about HIV are not stable. \u0026ndash; HIV counsellor\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003e \u003cb\u003eCharacteristics of Individuals\u003c/b\u003e \u003cb\u003e(belief in the intervention, individual identification and capacity, passion)\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003cp\u003eMost participants believed that the CoCM can potentially provide more holistic care that may help in early detection of mental health disorders and improve retention to care, treatment adherence, quality of life and patient empowerment. However, some participants thought that the CoCM would only be helpful if sustained. Some patients and HIV providers also expressed preference for a separate mental health program with healthcare providers specific for mental health care.\u003c/p\u003e \u003cp\u003eMost providers recognized that HIV counsellors are commonly the first contact of patients in the clinic making them the practical and acceptable option for doing mental health assessment and referral. HIV physicians are sometimes treated as family physicians and long term carers for any medical or psychosocial concerns, giving them the opportunity to do mental health assessment and management. Most participants believed that patients may already have trust, comfort and rapport with their HIV providers which may help with their mental health management.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHIV providers expressed a passion for helping patients and a willingness to be trained on mental health and participate in the CoCM for the benefit of patients despite heavy workloads.\u003c/p\u003e\u003cp\u003e\u003cem\u003eI already knew that their (HIV counsellors\u0026rsquo;) passion is really for the patients\u0026hellip;. even if this is an additional task, they will really take that additional task wholeheartedly\u0026hellip;there is the satisfaction they can get, to a certain degree they helped their patient, I mean with their holistic health. -HIV counsellor\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHowever, according to HIV counsellors and physicians, HIV providers need to be prepared for their role in the CoCM, which includes not only the responsibilities, but their own mental health as well to avoid burnout. Some mental health providers also expressed their willingness to be a part of the CoCM and believed other psychiatrists may be also willing. However, an HIV physician and mental health provider still felt that identifying willing psychiatrists could be a challenge.\u003c/p\u003e\u003cp\u003eSeveral participants believed that HIV counsellors\u0026rsquo; trainings and capacity for HIV counselling and experience in using screening tools would be helpful for the role of care manager in the CoCM. HIV physicians were thought to already possess basic knowledge about mental health disorders. However, some pointed out that HIV counsellors have diverse training backgrounds, educational levels, knowledge and skills for providing mental health care. Some HIV physicians shared having low confidence, inadequate knowledge and formal training in mental health assessment and management, especially with pharmacotherapy.\u003c/p\u003e\u003cp\u003e\u003cem\u003eThat\u0026rsquo;s a good idea. But maybe we still need a lot of training because maybe we\u0026rsquo;re not doing it habitually. Maybe it\u0026rsquo;s not our forte anymore, but we are willing to learn. -HIV physician\u003c/em\u003e\u003c/p\u003e\u003cp\u003eA few HIV providers also mentioned that psychiatrists\u0026rsquo; knowledge of HIV concerns and needs may be inadequate, and they may need to learn more about the unique struggles of PLHIV.\u003c/p\u003e\u003cp\u003e\u003cb\u003eProcess\u003c/b\u003e\u003cb\u003e(planning, executing, evaluation and monitoring)\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Most participants emphasized the need for training both HIV providers and psychiatrists to implement the CoCM. With differences in individual capacity, participants suggested that different levels of mental health training, and HIV training for psychiatrists, would be needed for various providers. Several suggested ways to bolster mental health training included utilizing the World Health Organization mhGAP, incorporating mental health trainings more intensively in HIV trainings, holding separate trainings specifically for mental health issues of PLHIV, or providing mentoring in HIV clinics that have access to a psychiatrist. Ideally, these activities would be free and can be done synchronously or asynchronously for the whole care team to be able to participate. A policymaker expressed that social workers and HIV nurses can also be care managers in the CoCM and other staff with interactions with PLHIV should be considerd for participation in mental health training.\u003c/p\u003e \u003cp\u003e \u003cem\u003eUtilizing our (HIV) case manager is a good idea. However, we need to make sure they are properly trained\u0026hellip; I don\u0026rsquo;t think there\u0026rsquo;s adequate sessions or training for mental health diagnosis and management (in HIV counselling training), so it should be part of the program before. And then there should also be a tool to assess whether they are indeed capable of assessing and managing mental health issues of patients..\u0026rdquo; \u0026ndash; HIV clinic head\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHIV providers, clinic directors, and policymakers highlighted the need to have a clear protocol, service delivery integration, and proper evaluation and monitoring for the CoCM to be acceptable and feasible. Pilot testing was thought to be important, with some already willing to pilot with their current available resources. Others expressed the need for the CoCM to be piloted in different HIV clinics in the country to assess feasibility and effectiveness and seek funding before they integrate mental health in their HIV clinic.\u003c/p\u003e \u003cp\u003e \u003cem\u003eIt's just like, formalizing or adapting it. At least like you have an ideal set up, then you have in a resource limited setting, you can start with what is available and then you just improve to reach the ideal.\u0026ndash; HIV counselor\u003c/em\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eOther recommendations in planning for the CoCM included adding suicidal risk and substance use assessment, scales for spirituality due to its effect on mental health in the Filipino culture, and incorporating mental health screening as early as HIV testing. A mental health provider suggested that planning should involve consultation with local mental health professionals in the Philippines and other experts, such as anthropologists, sociologists, local tribe leaders, and PLHIVs, accustomed to the local culture.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study showed stakeholder acceptability of implementing the CoCM in HIV clinics and identified potential barriers and facilitators supporting the feasibility across the five domains of the CFIR. Our findings emphasized the need to improve current mental health services in HIV care and the need to train HIV providers in mental health. Participants identified potential strategies tailored for the local HIV clinics settings that may increase stakeholder buy-in prior to implementation. To our knowledge, this is the first study in the Philippines to explore the use of the CoCM in HIV clinics.\u003c/p\u003e \u003cp\u003eFor intervention characteristics, participants identified the adaptability and use of evidence-based interventions in the CoCM as facilitators, while implementation cost and the inadequate number of psychiatrists were barriers. Although some partcipants already had previous experiences in using mental health screening tools, some expressed the need to translate it in the local language, which may impact its understandability. In Kosrae, an island state in Micronesia, mental health screening tools for the CoCM were still not clearly understood despite translating to the local language. Study staff therefore adapted the screening to be more conversational (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The lack of access to psychiatrists has been identified in other LMICs as well (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Teleconsultation or teleconferencing with the psychiatrist has been shown to be effective in other settings, which was also recommended in this study (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Implementation costs for health staff, computers or phones, and clinic spaces are also a common barrier mentioned in other CoCM studies, not only in terms of feasibility but also for sustainability despite effective implementation (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The Philippine health insurance budget on HIV and mental health services should be explored as a means to fund the CoCM.\u003c/p\u003e \u003cp\u003eIn the outer setting, meeting patients\u0026rsquo; needs through use of a more holistic care model and local policies, supported the acceptability of CoCM. Collaborations within or across clinics or hospitals to access psychiatrists and psychotropics were identified as facilitators. Participants in this study believed the CoCM can potentially address both HIV and mental health stigma, similar to a finding in the CoCM implemented in primary clinics in northwest England where delivery of mental health care was less stigmatized when incorporated in other clinial management (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). These findings were in contrast to other studies where mental health stigma, among both patients and providers, low awareness of depression, and lack of trust in primary care providers were identified as barriers in participating in the the CoCM (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePolicies in the Phillippines that may support the CoCM are the Universal Health Care Act, which aims to provide quality and accessible health care to all Filipinos, and the Mental Health Act, which aims to integrate mental health care in basic health services (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The Guidance and Counselling Act in the Philippines, however, was mentioned as a possible barrier as only registered guidance counsellors are allowed to provide counselling and psychological testing in this law. Hence, it may potentially restrict HIV counsellors, who are not guidance counsellors, from providing low intensity therapies and mental health screening (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). In the HIV law, however, HIV counselling can include exploring PLHIV\u0026rsquo;s personal issues, identifying ways of coping with anxiety and stress, and helping resolve personal, social and psychological problems and difficulties in the context of an HIV diagnosis (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Despite the Guidance and Counselling Act, most participants still believed HIV counsellors can be care managers in the CoCM.\u003c/p\u003e \u003cp\u003eIn the inner setting, participants in this study stressed the need to strengthen mental health services in HIV clinics. However, availability of clinic staff, workload, and lack of support among those leading HIV and mental health services were possible barriers. Similarly, staff shortage and employee turnover increased workload leading to less time for patients. Lack of leadership engagement may affect staff turnover. These are barriers found in other studies from both LMIC and high-income countries (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In our study, participants identified city mayors as important leaders who need to be engaged, as health programs and services in government or community primary HIV clinics are under their leadership. Similarly, Ngo et al. emphasized the importance of engaging political, administrative, health and mental health leaders for effectively implementing the CoCM in Vietnam (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e Participants acknowledged that characteristics of individuals, including HIV providers\u0026rsquo; primary role in HIV care and patients\u0026rsquo; trust in providers, passion in delivering high quality care for PLHIV, and current knowledge and skills in HIV counselling supported acceptability. However, lack of mental health knowledge among HIV providers was emphasized as a barrier, a common finding in other CoCM studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Conducting a baseline assessment of HIV providers\u0026rsquo; skills and core competencies in mental health management can help assess their self-efficacy and prepare for their roles in the CoCM. The study in Kosrae found that psychiatrists who developed a deeper understanding of the local culture gave more appropriate mental health recommendations to the care team (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). HIV providers in this study felt that some psychiatrists may need to increase their knowledge about HIV, which could help deliver more tailored care. Providers\u0026rsquo; expressed passion for caring for PLHIV may be similar to the CoCM for older people in China where the care team members\u0026rsquo; care for the elderly supported their willingness to participate in the CoCM and was thought to be a factor in its effectiveness in reducing depressive symptoms. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). In contrast, other studies showed resistance from clinic staff and a lack of willingness to change due to the additional responsibilities among an already overburdened staff (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In Nepal and Vietnam, observing improvement in patients\u0026rsquo; outcomes and targeting the values of providers by emphasizing their roles as change agents improved acceptability and participation in the CoCM (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Importance of having trust in providers has also influenced the acceptability of the CoCM in HIV clinics in the US and in China, with patients being more comfortable and truthful with the care team when trust is present (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). It is important to note, however, that some PLHIV and HIV providers in this study still expressed a preference for separate physical and mental health care. In a primary care clinic in England, the authors found that integrating mental health in primary care can undermine mental health management, especially if the mental health condition is explored in the context of patients\u0026rsquo; medical condition, which may be given higher priority (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In the context of this study, not all mental health conditions may be related to a person\u0026rsquo;s HIV status. These preferences may impact the acceptability and success of implementing the CoCM and may inform the design of a more flexible model of care, such as access to specialists or designating clinic staff specific for delivery of mental health care (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eRecommendations for implementing the CoCM included training HIV providers, establishing clear processes, pilot testing, and tailoring implementation to the local setting and culture. Adequate training of both HIV and mental health providers is crucial and has enhanced motivation to participate in the CoCM (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In Vietnam and India, other personnel - including nurses, village health collaborators and health workers, social workers, and even nutritioninsts - were trained for the role of care managers (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). This broadened approach is congruent with the findings in this study that recommended that all clinic staff with any patient interaction should be trained for providing mental health care. Unclear processes and role confusion by the care team physicians and counsellors have been identified as barriers in implementing the care team approach (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Hence, establishing a clear work flow, care team roles, and standardizing the implementation process are necessary for the the CoCM to be acceptable. However, when a US clinic implemented the CoCM, the time it took to develop the tools and processes prior to implementation may have had a negative effect by slowing down the implementation process. In other studies, a trial and error approach has helped by testing a process and making adjustments after (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Pilot testing the CoCM in HIV clinics in the Philippines would help tailor it to the available resources and local cultural context, and assess its effectiveness to increase stakeholder buy-in and support future funding, as seen in other studies (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations with regard to generalizability in HIV clinics in the Philippines. Despite including providers and patients from different types of HIV clinics (private, government, hospital-based and stand-alone clinics), organizational settings and culture may still differ by individual clinic, which may correspond to differences in barriers and facilitators. Participants interested in joining the study may have had heightened awareness about the importance of mental health, which may have influenced their perceived acceptability. Women living with HIV, who may have different perspectives, were also underrepresented in this study. Lastly, as this is a formative pre-implementation study, acceptability, barriers and facilitators may differ in the implementation phase.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003e Participants perceived the CoCM to integrate mental health in HIV care using HIV counsellors as care managers in HIV clinics in the Philippines as acceptable. Perceived barriers included inadequate numbers of psychiatrists in the country, an overburdened and understaffed workforce in HIV clinics, and inadequate mental health knowledge among HIV providers. Facilitators and recommendations included training HIV and mental health providers, intra- and inter-clinic collaborations to facilitate better access to psychiatrists, proper planning with standardized processes, and pilot testing to implement the CoCM in an acceptable and feasible way in HIV clinics in the Philippines.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCFIR \u0026nbsp; \u0026nbsp; \u0026nbsp;Consolidated Framework for Implementation Research\u003c/p\u003e\n\u003cp\u003eCoCM \u0026nbsp; \u0026nbsp;Collaborative Care Model\u003c/p\u003e\n\u003cp\u003eFGD \u0026nbsp; \u0026nbsp; \u0026nbsp; Focus group discussions\u003c/p\u003e\n\u003cp\u003eKII \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Key informant interviews\u003c/p\u003e\n\u003cp\u003eLMIC \u0026nbsp; \u0026nbsp; \u0026nbsp;low-and-middle income countries\u003c/p\u003e\n\u003cp\u003emhGAP \u0026nbsp; Mental Health Gap Action Programme\u003c/p\u003e\n\u003cp\u003ePLHIV \u0026nbsp; \u0026nbsp;Person living with HIV\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the Research Institute for Tropical Medicine Institutional review board with IRB protocol number 2020-41. All participants in this study signed an informed consent and all methods done were in accordance to the approved IRB protocol. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported\u0026nbsp;through a grant from amfAR, The Foundation for AIDS Research, with support from the US National Institutes of Health’s Fogarty International Center and the National Institute of Mental Health (CHIMERA; D43TW011302).\u0026nbsp;This work is solely the responsibility of the authors and does not necessarily represent the official views of any of the institutions mentioned above.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eADL is the principal investigator and was involved in the conceptualization and planning of the study and led the implementation, data analysis and writing of the manuscript. JM was involved in reviewing the data analysis, writing, design and finalization of the manuscript. AS was involved in conceptualization and planning of the study, reviewed and revised the final manuscript. RD was involved in the conceptualization and planning of the study. MM was involved in the conceptualization of the study and review of the manuscript. RT was involved in the implementation of the study and data analysis as the research assistant of the principal investigator. TD was involved in the conceptualization of the study and assisted in data management.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe want to express our gratitude to TREAT Asia, Columbia University and the CHIMERA training program for their support in this study. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors’ information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResearch Institute for Tropical Medicine, Manila, Philippines\u003c/p\u003e\n\u003cp\u003eAnna Maureen Dungca-Lorilla MD\u003c/p\u003e\n\u003cp\u003eRossana Ditangco MD\u003c/p\u003e\n\u003cp\u003eTimothy John Dizon MD\u003c/p\u003e\n\u003cp\u003eRoxanne Emily Tanuecoz RPm\u003c/p\u003e\n\u003cp\u003eColumbia University, Department of Psychiatry, New York, USA\u003c/p\u003e\n\u003cp\u003eJennifer Mootz PhD\u003c/p\u003e\n\u003cp\u003eTREAT Asia, amfAR- The Foundation for AIDS Research, Bangkok, Thailand\u003c/p\u003e\n\u003cp\u003eAnnette Sohn MD PhD\u003c/p\u003e\n\u003cp\u003eAteneo De Manila University, Philippines\u003c/p\u003e\n\u003cp\u003eMaria Isabel Melgar PhD\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSoliman B, Reyes ME. 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May 2023.\u003c/li\u003e\n\u003cli\u003eEthnic Groups of the Philippines. Languages in the Philippines [Available from: http://www.ethnicgroupsphilippines.com/languages-in-the-philippines/.\u003c/li\u003e\n\u003cli\u003eEthnicity in the Philippines (2020 Census of Population and Housing): Philippine Statistics Authority; 2023 [Available from: https://psa.gov.ph/content/ethnicity-philippines-2020-census-population-and-housing.\u003c/li\u003e\n\u003cli\u003eReligious Affiliation in the Philippines (2020 Census of Population and Housing): Philippine Statistics Authority; 2023 [Available from: https://psa.gov.ph/content/religious-affiliation-philippines-2020-census-population-and-housing.\u003c/li\u003e\n\u003cli\u003eWood E, Ohlsen S, Ricketts T. What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review. J Affect Disord. 2017;214:26-43.\u003c/li\u003e\n\u003cli\u003eHaack SA, Rehuher D, Ghiasuddin A, Kiyota T, Alik TP. Implementation of an Adapted Collaborative Care Model. Psychiatr Serv. 2022;73(10):1186-9.\u003c/li\u003e\n\u003cli\u003eKnowles SE, Chew-Graham C, Adeyemi I, Coupe N, Coventry PA. Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model. BMC Fam Pract. 2015;16:32.\u003c/li\u003e\n\u003cli\u003eFu E, Carroll AJ, Rosenthal LJ, Rado J, Burnett-Zeigler I, Jordan N, et al. Implementation Barriers and Experiences of Eligible Patients Who Failed to Enroll in Collaborative Care for Depression and Anxiety. J Gen Intern Med. 2023;38(2):366-74.\u003c/li\u003e\n\u003cli\u003eTuason MT, Alvarez, Margaret, Stanton Bridget. The Counseling Profession in the Philippines. Australian Counselling Research Journal. 2021.\u003c/li\u003e\n\u003cli\u003eAndrea Marie AB, Merlita VC, Joseph Gedeoni CV. Implementation, Best Practices, and Challenges in Mental Health Strategies among Local Government Units in the Province of Negros Occidental, Philippines. Philippine Social Science Journal. 2022;5(2).\u003c/li\u003e\n\u003cli\u003eLi LW, Xue J, Conwell Y, Yang Q, Chen S. Implementing collaborative care for older people with comorbid hypertension and depression in rural China. Int Psychogeriatr. 2020;32(12):1457-65.\u003c/li\u003e\n\u003cli\u003eFuller SM, Koester KA, Erguera XA, Wilde Botta E, von Beetzen F, Steward WT, et al. The collaborative care model for HIV and depression: Patient perspectives and experiences from a safety-net clinic in the United States. SAGE Open Med. 2019;7:2050312119842249.\u003c/li\u003e\n\u003cli\u003eWhitfield J, Owens S, Bhat A, Felker B, Jewell T, Chwastiak L. Successful ingredients of effective Collaborative Care programs in low- and middle-income countries: A rapid review. Cambridge Prisms: Global Mental Health. 2023;10:e11.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4780343/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4780343/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDepression and anxiety can greatly impact the overall health of a person living with HIV (PLHIV). Management of mental health conditions should be an integral part of HIV care. The Collaborative Care Model (CoCM) is an evidence-based model of care that integrates mental health in primary care. This study aimed to assess the acceptability and feasibility of implementing the CoCM for depression and anxiety in HIV clinics in the Philippines using HIV counsellors as care managers.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study by facilitating focus group discussions (n\u0026thinsp;=\u0026thinsp;7) and key informant interviews (n\u0026thinsp;=\u0026thinsp;18) with 53 HIV and mental health stakeholders, including PLHIV (n\u0026thinsp;=\u0026thinsp;20), HIV counsellors (n\u0026thinsp;=\u0026thinsp;11), physicians (n\u0026thinsp;=\u0026thinsp;10), clinic heads (n\u0026thinsp;=\u0026thinsp;4), policy makers (n\u0026thinsp;=\u0026thinsp;4), and mental health providers (n\u0026thinsp;=\u0026thinsp;4) from August 2021 to March 2022. Participants were recruited from 17 HIV clinics in the Philippines. We employed a thematic analysis using the Consolidated Framework for Implementation Research (CFIR) domains as themes.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAlmost all PLHIV participants were men (95%), with a mean age of 28 years old, while 58% of the other stakeholders were women, with a mean age of 44 and working in their field for an average of 8 years. Factors that influenced acceptability of the CoCM included the need for better mental health services, increasing access to mental health care and providing more holistic care. Participants expressed acceptability for HIV providers to do mental health screening and care due to the trust that had previously been built during their HIV care. Perceived barriers included inadequate numbers of psychiatrists, an overburdened and understaffed HIV workforce, low mental health knowledge among HIV providers, and implementation cost. For the CoCM to be feasible and more acceptable, mental health trainings, collaborations for improved access to psychiatrists (e.g., within and across clinics), clear care integration protocols, proper planning and pilot testing were recommended.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eWe found the CoCM to be acceptable among study participants as a way to integrate mental health in HIV care. Strategies including capacity-building for HIV providers and strengthening of health systems are needed for the CoCM to be more feasible in HIV clinics in the Philippines.\u003c/p\u003e","manuscriptTitle":"Acceptability and Feasibility of a Task-Shifted Collaborative Care Model for Depression and Anxiety in Primary HIV Clinics in the Philippines: A Qualitative Inquiry","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-08-19 14:41:11","doi":"10.21203/rs.3.rs-4780343/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-25T10:42:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-25T05:26:49+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-07-23T11:46:33+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-07-22T08:34:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af18c33d-1911-4644-b02e-f92e5124e0ba","owner":[],"postedDate":"August 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T16:01:56+00:00","versionOfRecord":{"articleIdentity":"rs-4780343","link":"https://doi.org/10.1186/s12913-025-12703-y","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-05-08 15:57:31","publishedOnDateReadable":"May 8th, 2025"},"versionCreatedAt":"2024-08-19 14:41:11","video":"","vorDoi":"10.1186/s12913-025-12703-y","vorDoiUrl":"https://doi.org/10.1186/s12913-025-12703-y","workflowStages":[]},"version":"v1","identity":"rs-4780343","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4780343","identity":"rs-4780343","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}