Participant recruitment.

We recruited 20 AGYW and 10 healthcare providers for participation in qualitative in-depth interviews between 16th February and 14th June 2021. AGYW were recruited from Thika sub-County Hospital and the PHRD clinic. Healthcare providers were recruited from Thika sub-County Hospital and six surrounding facilities to capture broader perspectives on mental health service delivery to AGYW within the larger catchment area that provides referrals to the primary study site.

AGYW were referred for study-related screening and enrollment by HIV care providers from Thika sub-County Hospital and the PHRD clinic. Eligible AGYW were aged 16–25 years and were currently receiving HIV prevention, treatment, or testing services at either clinic at the time of enrollment. HIV care providers at the two facilities were sensitized about the study to support the recruitment of AGYW by identifying potential participants while providing HIV services. Once the providers identified AGYW who fit the eligibility criteria, they informed the AGYW about the study and referred those who expressed willingness for study participation to the study staff at the PHRD clinic (approximately 1.5 kilometers distance) for screening and enrollment. This assured AGYW of confidentiality, enhanced their comfort in study participation, and built trust between the AGYW and the study staff. Once the AGYW arrived at the PHRD clinic, they were screened for study participation by a study psychosocial counselor in a private clinic room using the Self Reporting Questionnaire 20-item (SRQ-20) mental health screening tool [38] (S1 File), to assess for elevated symptoms of CMDs. AGYW with mild-to-moderate CMD symptoms (determined by a score of 7–14 on the SRQ-20 screening tool), were eligible for in-depth interviews. AGYW with scores above 14, indicating severe CMD symptoms, were excluded from interviews due to potential impacts on the capacity to consent to study participation, and risk of harm related to emotional distress from discussing sensitive topics or traumatic experiences [39]. These AGYW were instead referred to a study clinical psychologist for psychosocial support.

We recruited providers from surrounding HIV and mental healthcare facilities. The providers were eligible if they were aged ≥18 years and had a current role in providing HIV or mental health services in an HIV, mental health, or primary healthcare facility located around Thika and Nairobi areas. The providers were recruited physically during in-person facility visits or using phone calls through which they were invited for study participation.

Participant sampling.

We used stratified purposive sampling to capture varied experiences of mental health service delivery among different demographic groups [40]. We included AGYW in different age groups (16–18, 19–22, and 23–25). These AGYW were receiving a variety of HIV prevention and treatment services including: PrEP, HIV testing services (HTS), post-exposure prophylaxis (PEP), and antiretroviral therapy (ART).

We also purposively sampled HIV and mental healthcare providers to include different cadres (HIV counsellors, clinical officers, nurses, psychiatrists, and psychologists), healthcare facility representation, service delivery experience, and educational backgrounds (college diploma and university degree). The overall sample size of 20 AGYW and 10 providers was determined by thematic saturation, whereby we stopped interviews once no new data emerged [40].

Individual-level risk factors for CMDs.

Among AGYW living with HIV, HIV stigma was a common risk factor for experiencing CMDs. This included internalized stigma attributed to challenges coming to terms with their HIV status, fear of intimate relationships due to negative self-image related to their HIV-positive status, fear of rejection, and fear of potentially transmitting HIV to their sexual partners. Among AGYW without HIV, CMD symptoms were linked to financial constraints, especially among single-parenting adolescents, and SRH issues such as unintended pregnancy, post-abortion, and post-partum complications. Other issues included infertility, sexually transmitted infections (STIs), and challenges negotiating condom use and HIV testing with sexual partners, as one AGYW seeking PrEP reported below:

The time I was feeling stressed was when I got pregnant and the young man that I loved left, and he said that he did not even want the pregnancy…I was so stressed, and I was asking myself why.” (AGYW, Age 20, Seeking PrEP, SRQ-20 Screening Score 10).

Interpersonal and community-level risk factors for CMDs.

Among AGYW living with HIV, CMD symptoms were also attributed to experiences of HIV-related stigma from discrimination, abuse, and withholding of emotional, material, and treatment support by peers, partners, and caregivers due to AGYW’s HIV status. Furthermore, perceived and anticipated HIV-related stigma was related to lack of privacy in HIV clinics, schools, and the community, which presented a risk of inadvertent HIV status disclosure and affected discreetness in taking medication. These factors contributed to mental health distress among AGYW living with HIV, as one AGYW described her stressful experience of taking ART medication while in school:

After being told [about my HIV status] I was very stressed, because you would wonder, you have gone to high school, and it is a boarding school, and you are taking those drugs. It becomes a challenge…it is only you using the drugs, and for those drugs, it is a must…So, it got to a point that students started asking me, “Which problem is this—every morning and you have to keep a certain time!” (AGYW, Age 18, Seeking ART, SRQ-20 Screening Score 12).

Among AGYW without HIV, mental health symptoms were mostly related to relationship problems, including emotional and physical abuse, mistreatment and violence by partners and caregivers, conflicts and separations among parents, sexual violence, and pressure from peers and community members for AGYW to attain certain high life goals and lifestyles.

AGYW experiences of mental health service delivery.

Less than half of the AGYW reported having ever received mental health services within HIV clinics, and the majority did not know where to access the services if they needed them. However, we found that most AGYW who reported receiving mental health services in HIV clinics had only received HIV adherence counseling and follow-up specific to HIV and STI prevention and treatment services (e.g., HIV testing, HIV status disclosure, and medication adherence) from HIV counseling providers, as one AGYW seeking HTS and PEP described below:

Okay, what she [provider] did is the counseling: she told me about how I can protect myself, about how I can also use PrEP, she also told me about how I am going to take my medication (PEP). Yeah, she just told me about preventive measures; about how I can also cope with people who are HIV-positive [living with HIV] and not get infected. (AGYW, Age 24, Seeking HTS/PEP, SRQ-20 Screening Score 11).

A few AGYW had received mental health counseling related to gender-based violence, unintended pregnancy, relationship challenges with partners, and HIV stigma, from providers based at healthcare facilities within their communities. These AGYW described four broad strategies they used to access the mental health services: (1) approaching providers and asking for help; (2) referral from one provider to another; (3) providers approaching AGYW presenting with mental health symptoms; (4) and caregivers seeking support from providers on behalf of AGYW. However, within HIV clinics, AGYW typically received only the specific HIV services they sought from providers, and some were not offered any mental health services while receiving services like HIV testing or ART, despite needing it. AGYW said that receiving mental health support from HIV care providers would be beneficial for getting relief from mental health burdens, empowering them, and helping them potentially find solutions to their problems, as one AGYW seeking HTS and PEP described below:

I know the benefits of being counseled, I know you can get help, you cannot drown in your stress or in those mental issues. It helps you; you can be able to move on, [and] you can be able to accept…Being counseled is helping me accept that it already happened, and we can’t undo it. (AGYW, Age 18, Seeking HTS/PEP, SRQ-20 Screening Score 7).

Despite their varied experiences with receiving mental health services, AGYW generally perceived mental health services positively, recognized their importance, and expressed a high demand, acceptability, and willingness to receive the services within HIV clinics.

Provider experiences of mental health service delivery.

Among HIV care providers, experiences with mental health service delivery to AGYW were mostly related to addressing stress and anxiety symptoms. However, mental healthcare providers had experience with addressing more severe psychotic and depressive symptoms among AGYW. Generally, mental healthcare providers felt more comfortable, competent, and confident in delivering mental health services to AGYW than HIV care providers. HIV care providers’ lower confidence in providing mental health services was mainly due to limited skills. Mental health services provided by HIV and mental healthcare providers included screening, mental health counseling, and referrals. Screening was primarily conducted by clinical assessment of clients’ history and symptoms. However, more specific screening tools were also used for further CMD diagnosis. Among both HIV and mental healthcare providers, mental health counseling provided to AGYW was mostly related to addressing internalized HIV and mental health stigma, social issues like abuse, gender-based violence, and conflicts among AGYW and their caregivers or partners, SRH issues such as unintended pregnancies, and contraceptive use, substance use addiction, grief, and life skills. HIV and mental healthcare providers also provided referrals for AGYW to other specialists or facilities for further evaluation and diagnosis of CMDs, as well as linkages to support groups for mental health, medication adherence, and substance use addiction issues, as one mental healthcare provider narrated below:

We also do support groups, just to help them [AGYW] have an appreciation that: one, they are not alone, they are quite a number, and two, as they share, they can also share different strategies and information about how best to cope with the different challenges that they are facing. So, it is very key in terms of provision of services at the youth center—I mean at the…‘Facility X’ HIV clinic. (Male Psychiatrist, HIV Clinic).

Routine mental health screening and referrals within HIV clinics.

Routine mental health screening and referrals within HIV clinics were limited to AGYW living with HIV with high viral load or serious adherence issues. Screening tools used included CAGE-AID [49] and CRAFFT [50] for alcohol and drug abuse screening, Morisky Medication Adherence Scale (MMAS-4) [51] for adherence screening, and Patient Health Questionnaire-9 (PHQ-9) [52] for depressive symptoms screening. These tools were integrated into the Electronic Medical Records (EMR) system, for screening clients with high viral load, to rule out mental health or substance use issues as possible adherence barriers. HIV care providers provided referrals to AGYW if they felt unequipped to offer them mental health support, and if AGYW were uncooperative or preferred specific providers. Most AGYW referrals were done through ‘referral by escort’, whereby HIV care providers physically escorted AGYW to relevant providers, e.g., psychologists located within HIV clinics, or externally to mental health clinics located within the facility. This ensured AGYW reached referral points and enabled HIV care providers to introduce AGYW and brief the mental healthcare providers about their case, ensuring AGYW’s comfort and cooperation to share their issues with providers, as one HIV care nurse reported below:

Mostly, we encourage escorting them [AGYW] to those referral centers. If you think the client is having anxiety or depression, you just take her to the psychologist…but you have to escort [them]; otherwise, if you tell them to go, they won’t go, because they won’t be able to open up to everybody. (Female Nurse, HIV Clinic).

AGYW individual and interpersonal-level factors.

Various factors influenced AGYW’s decisions to access mental health services within HIV clinics including receiving services from familiar providers, attending few service points, short waiting times, flexible clinic operating hours, and incurring no costs for services. Positive interpersonal experiences with providers, including perceived good quality reception, empathy, and competency, also motivated AGYW to seek mental health services. AGYW preferred providers they perceived as welcoming and friendly, used polite language, listened, showed genuine interest, reassured and encouraged them to talk, and were non-judgmental, as one AGYW seeking PrEP narrated below:

You know, you could also enter the room, and you feel that that [provider] is not even a person to share your problems with, and you would rather even leave…There are those [providers] you usually find are in a bad mood all the time, and they usually don’t even greet you. (AGYW, Age 23, Seeking PrEP, SRQ-20 Screening Score 9).

The key obstacles to AGYW accessing mental health services included preferences related to provider demographic characteristics such as age and gender while seeking services in HIV clinics, with most AGYW reporting being more comfortable with female providers. AGYW perceived younger providers as more likely to understand their issues, but mature providers as more empathetic, likely to maintain confidentiality, and more invested in their well-being. Other concerns among AGYW included provider confidentiality, embarrassment in sharing their issues with providers, especially during first clinic encounters, and fear of stigma and discrimination from being seen at the HIV clinics by people known to them, as one AGYW seeking HTS and PEP shared below:

What may make me—I may feel embarrassed because people know that this is an HIV clinic. So, “She is going because maybe she has HIV”. Yeah, the embarrassment that comes with it. (AGYW, Age 18, Seeking HTS/PEP, SRQ-20 Screening Score 7).

Provider individual and interpersonal-level factors.

Overall, HIV and mental healthcare providers felt motivated to provide mental health services to AGYW, but various factors affected their ability and willingness to deliver the services. Among HIV care providers, inadequate mental health training (e.g., related to knowledge of screening tools and AGYW-friendly communication, including rapport-building and empathy skills) was a key barrier to mental health service delivery. Conversely, mental healthcare providers had adequate training and considered mental health services as their core evaluable role. Consequently, most HIV care providers preferred referring AGYW with CMDs to HIV clinic adherence teams—comprised of psychologists and HIV counselors—or other trained providers. HIV care providers also reported difficulties when counseling AGYW with persistently high viral loads, noting that these AGYW often became angry with providers, refused to answer adherence-related questions, and defaulted on their monthly clinic visits, as one provider described below:

The challenge comes with the high viral load ones [AGYW] where you have now to see them every month and ask, “Why, why, why is your viral load up?” It gets to a point when they start getting angry at you. So, they get angry at you and then they start just keeping quiet at you, so it is you now to decide how you will probe and get to the bottom of the issues…So, like those ones now…I can refer very fast. (Male Clinical Officer, HIV Clinic).

Furthermore, some HIV clinic staff perceived AGYW as ‘not easy to work with’, ‘troublesome’, or ‘difficult’ clients that required a lot of provider time and patience. Others reported difficulty in understanding words and language AGYW used during counseling, while others perceived mental health services as ‘extra work’.

Conversely, among mental healthcare providers, key challenges included difficulty of AGYW gaining insight (i.e., ability to recognize and accept their CMD symptoms), AGYW declining mental health services and medication, mental health stigma, and lack of treatment support from caregivers and partners. Mental healthcare providers also reported observing stigma and discrimination from other providers, especially those in non-psychiatric departments, who avoided interacting with clients with mental health disorders and used stigmatizing words like ‘Mwendawazimu’ (Kiswahili- mad person) to refer to clients, as one mental healthcare nurse expressed below:

In a general outpatient like in a certain hospital, you find that there are those providers who do not want completely to be associated with those people with mental illnesses; they actually run away from them, they probably believe they might also be aggressive and violent and very harmful or dangerous people. (Male Nurse, Mental Health Clinic).

Service and structural-level factors.

Among HIV care providers, structural factors affecting mental health service delivery to AGYW included a lack of funds for provider training and inadequate rooms for adolescent-friendly consultations, which resulted in a lack of privacy for AGYW. HIV care providers also experienced difficulties escorting AGYW to and from mental health clinics for their referrals, due to challenges around lack of time, busy clinic workloads, and staffing shortages. Further concerns included the lengthy time needed to provide HIV services to AGYW since providers had to complete more documentation for AGYW aged up to 25 years who were in HIV care compared to adults. Providers also reported concerns about competing roles, high workload, time constraints related to high client volumes within public HIV clinics, and a lack of clear guidelines and practical tools to support HIV care providers on integrating mental health screening into HIV service delivery. These factors contributed to providers missing out on mental health within routine HIV care, as one clinical provider highlighted below:

I wish we had a—what should I call it? A defined tool that would guide you on specific, like the major ones [CMD symptoms] that we need to screen for…because most of the time, us clinicians miss [mental health screening]. You will miss [it] because maybe you forgot to ask, or maybe it is because there is no directive that you can ask directly. (Female Clinical Officer, HIV Clinic).

Among mental healthcare providers, poor referral pathways, which underprioritized AGYW referred from HIV clinics, resulted in long waiting times as AGYW had to queue for services twice—at HIV and mental health clinics. Furthermore, there was a lack of transportation for external referrals, unclear systems for tracking and follow-up of clients, and a lengthy time needed to provide screening and counseling to AGYW. Staffing shortages and high turnover also affected services, with the few available trained mental healthcare providers having to create time outside working hours to follow up clients. Limited resource allocation to mental health units within public health facilities, shortage of in-patient facilities, and restrictive facility policies further limited mental health services delivery to AGYW, as one mental healthcare provider described below:

In [public referral facility X], there is no admission for children; we don’t have a unit whereby we manage children under the age of 18 years. So, whoever is admitted has to be more than 18 years. But in [private facility Y], we do admit younger people, even children who suffer from mental illness. (Male Nurse, Mental Health Clinic).