"Everyone is fighting their own battles": A qualitative study to explore the context of suicidal ideation among people with HIV (PWH) in Kilimanjaro, Tanzania.
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2025-01
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Tanzania faces significant HIV-related challenges with 1.4 million people currently living with HIV, 33,000 new infections, and 22,000 AIDS-related deaths annually. Suicide is a leading cause of death among People with HIV (PWH), with one-quarter of all deaths by suicide in Tanzania occurring among PWH. Despite this challenge, mental health resources are scarce, with only 55 psychologists and psychiatrists in the country, and clinic staff in HIV care lack adequate mental health training. This qualitative study explores the experiences of PWH who have recently had suicidal thoughts. The aim is to create targeted mental health interventions in Kilimanjaro. Participants were screened for suicidal ideation during routine care at two HIV clinics, with semi-structured qualitative interviews conducted thereafter. Data were analyzed using thematic analysis aided by NVivo 12 software. PWH experiencing suicidal ideation encounter multiple stressors related to their HIV diagnosis, societal stigma, financial stress, and broader social challenges. Suicide is sometimes viewed as an escape from these difficulties. Coping mechanisms include seeking assistance from family and religious leaders, but social support is hindered by fear of stigma. While participants expressed openness to counseling, treatment options were extremely limited. Suicide risk among PWH is influenced by stressors related to HIV, such as socioeconomic challenges, HIV stigma, low social support, and accompanying psychological distress. There is a clear need for improved mental health care options customized to the needs of PWH in Tanzania and other low-resource settings.
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Amiri, Ismail, Brandon A Knettel, Clotilda S Tarimo, Kearsley A Stewart, Aunchalee EL Palmquist, Judith M Mwobobia, Victor Katiti, Elizabeth Knippler, et al. (2025). "Everyone is fighting their own battles": A qualitative study to explore the context of suicidal ideation among people with HIV (PWH) in Kilimanjaro, Tanzania. PLOS mental health, 2(5). p. e0000318. 10.1371/journal.pmen.0000318 Retrieved from https://hdl.handle.net/10161/34304.
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Brandon Knettel
Brandon Knettel, Ph.D. is Associate Director of the Duke Center for Global Mental Health and an Associate Professor with a primary appointment in the Duke University School of Nursing and a secondary appointment in the Duke Global Health Institute. His areas of specialization are global mental health and health behavior, with a focus on care engagement, nurse-led models of care, stigma reduction, and mental health support for people living with HIV. At DGHI, he teaches a course in Global Mental Health for the Master's of Science in Global Health program.
Dr. Knettel’s international projects are primarily located in Moshi, Tanzania, where he completed a one-year VECD Fogarty Global Health Fellowship to evaluate a community health worker program for HIV care engagement. He also completed a NIMH K08 Career Development Award to develop a brief telehealth counseling intervention to address suicidal ideation and improve care engagement among people living with HIV and was co-PI of a DGHI pilot grant to improve the understanding of cancer-related stigma in Tanzania.
Kearsley A Stewart
Aunchalee E Loscalzo Palmquist
Dr. Aunchalee Palmquist is an Associate Professor of the Practice at the Duke Global Health Institute with a secondary appointment in Cultural Anthropology. She holds a PhD in Medical Anthropology from the University of Hawai’i at Mānoa and is an International Board Certified Lactation Consultant (IBCLC).
Dr. Palmquist is a global health equity scholar, feminist ethnographer, and internationally recognized breastfeeding and human lactation researcher. Her scholarship bridges biocultural medical anthropology and global health. Inspired by feminist anthropology, Indigenous methodologies, bioethics, and human rights frameworks, she uses research to uncover root causes of global health challenges and to imagine new directions for policy, practice, and advocacy. Dr. Palmquist has over 20 years of experience conducting ethnographic, mixed-methods, and community-based participatory research and collaborates on interdisciplinary research with scholars from around the world.
Prior to joining DGHI, Dr. Palmquist was an Assistant Professor at the UNC Chapel Hill Gillings School of Global Public Health and the Carolina Global Breastfeeding Institute. She was the 2021 recipient of a Gillings Faculty Award for Excellence in Health Equity Research and a two-time recipient of a Teaching Innovation Award in the Gillings School, Department of Maternal and Child Health (2020, 2023). Dr. Palmquist is the recipient of the 2024 American Anthropological Association's Solon T. Kimball Award for Practicing and Applied Anthropology and the 2024-2025 DGHI Graduate Professor of the Year award.
Dr. Palmquist has served as a CGBI representative on the WHO/UNICEF Global Breastfeeding Collective (2017-2023), the Emergency Nutrition Network IFE Core Group (2017-2023), and the United States Breastfeeding Committee as Co-Steward of the COVID-19 Infant and Young Child Feeding Constellation (2020-2023). Dr. Palmquist has previously served as an International Lactation Consultants Association liaison to the United Nations (2017). Her scholarship has been featured in the New York Times, BBC News, NPR, CNN, Associated Press, National Journal, and other media outlets. It has informed national policies and global health guidance related to breastfeeding in emergencies, human milk banking, and human milk sharing.
Kim Madundo
Michael Vernon Relf
Michael Relf, PhD, RN, ANEF, FAAN is the Mary T. Champagne Distinguished Professor of Nursing and Dean of the Duke University School of Nursing and a Research Professor in the Duke Global Health Institute. As Dean, Dr. Relf leads one of the nation's leading schools of nursing and a globally recognized institution for nursing education, research, clinical innovation, and community engagement. In this role, he has expanded need-based scholarships, increased pathways into nursing education, and championed access, belonging, and opportunity within the nursing profession. As a first-generation high school graduate who grew up in rural America, he is keenly aware of the power, privilege, and promise of higher education and nursing.
He is a nationally recognized nurse scientist, mentor, and educator, and influential academic leader whose work has advanced humanistic, stigma-free HIV care, health equity, global health, nursing workforce development, and nursing education.
He serves on the Board of Directors of the University of Global Health Equity in Rwanda. He has been a visiting professor at the University of Zululand (South Africa) and Queen’s University Belfast (Northern Ireland) and is a University Consulting Professor at Fudan University School of Nursing (China).
Areas of Expertise:
• HIV prevention, treatment, and care
• HIV-related stigma and discrimination
• Intimate partner violence and health outcomes
• Global health
• Nursing education
• Advanced practice nursing
• Nursing workforce development
• Community and population health
• Health equity and access to care
• Interprofessional and team-based care
• Academic health leadership
Dr. Relf's research focuses on the psychosocial aspects of HIV and the factors that influence health outcomes among people living with or at risk for HIV. Using mixed-methods approaches, he studies HIV-related stigma, intersectional stigma, everyday discrimination, intimate partner violence, and strategies that promote engagement in HIV primary care and treatment. His work has helped advance understanding of how social and structural factors affect health and wellbeing and has informed interventions designed to improve care, retention, and quality of life among individuals affected by HIV.
A central focus of his scholarship has been documenting and advancing the role of professional and advanced practice nurses in HIV prevention, treatment, and long-term care. His research has helped shape nursing practice, education, and competency development both nationally and internationally.
Dr. Relf's work examining the relationship between intimate partner violence and HIV risk behaviors among men who have sex with men received international media attention and was featured in major news outlets in North America and Europe. His research has contributed to broader conversations about violence, stigma, sexual health, and HIV prevention.
As a co-investigator on a President's Emergency Plan for AIDS Relief (PEPFAR)-funded initiative to strengthen nursing capacity in Southern Africa, Dr. Relf collaborated with nursing leaders in Botswana, Lesotho, Malawi, South Africa, Eswatini, and Zimbabwe to develop the Essential Nursing Competencies Related to HIV and AIDS. These competencies, endorsed by the International Council of Nurses, the Elizabeth Glaser Pediatric AIDS Foundation, and the Association of Nurses in AIDS Care, have since informed HIV nursing education and practice in multiple countries, including Canada and Thailand. He also led a national practice validation study to identify the competencies needed by nurse practitioners providing HIV specialty care.
His research has been supported by the National Institutes of Health (the National Institute of Nursing Research, the Fogarty International Center), the Health Resources and Services Administration, the President's Emergency Plan for AIDS Relief, the American Nurses Foundation, and Sigma Theta Tau International.
Leadership and Academic Administration
Dr. Relf has held several senior leadership positions at Duke University School of Nursing. From 2008 to 2014, he served as Assistant Dean for Undergraduate Education and Director of the Accelerated Bachelor of Science in Nursing Program. From 2014 to 2023, he served as Associate Dean for Global and Community Health Affairs, leading initiatives that expanded community partnerships, global engagement, and interdisciplinary collaboration. He was appointed Dean of the Duke University School of Nursing in 2025.
Prior to joining Duke, Dr. Relf served as Chair of the Department of Nursing at Georgetown University and as Associate Medical Administrator and Director of Nursing and Clinical Support Services at Whitman-Walker Clinic, a nationally recognized healthcare organization serving LGBTQ+ communities and individuals affected by HIV.
Honors and Distinctions
Dr. Relf is an Advanced HIV/AIDS Certified Registered Nurse (AACRN) and Certified Nurse Educator (CNE). He is a Fellow of the American Academy of Nursing and a Fellow of the Academy of Nursing Education of the National League for Nursing.
His contributions to nursing, HIV care, research, and mentorship have been recognized through numerous national awards, including:
• President's Award, Association of Nurses in AIDS Care (2024)
• Researcher Recognition Award, Association of Nurses in AIDS Care (2017)
• Distinguished Alumnus Award, South Dakota State University (2014)
• Spirit of Nursing Award for Mentoring (2006)
• Frank Lamendola Achievement Award for Nursing Leadership in HIV Care (2003)
Media and Speaking Topics
• Future of nursing
• Nursing workforce shortages
• HIV prevention and treatment
• HIV stigma and discrimination
• Global health
• Academic health leadership
• Nursing education innovation
David Brian Goldston
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