"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.
Michael Vernon Relf
Michael Relf, PhD, RN, ANEF, FAAN, is the Mary T. Champagne Distinguished Professor of Nursing and Dean in the Duke University School of Nursing and a Research Professor in the Duke Global Health Institute. From the period 2008-2014, he served as the Assistant Dean for Undergraduate Education and Director of the Accelerated BSN Program in the School of Nursing at Duke University. From 2014-2023, he served as the Associate Dean for Global and Community Health Affairs.
His research focuses on the psychosocial aspects of HIV using mixed-methods particularly focusing on intimate partner violence; HIV-related stigma, intersectional stigma, and experiences with everyday discrimination among persons living with HIV; and interventions to promote engagement in HIV-oriented primary medical care and disclosure. Additionally, through his research, he has documented the role of the professional and advanced practice nurse in the prevention, care and treatment of persons at risk for or living with HIV.
Dr. Relf has examined the relationship between intimate partner violence and HIV risk behaviors among men who have sex with men. This work received international press attention (Germany, France, Chile, United Kingdom, Romania, Turkey, Spain) and appeared on the front page of The Boston Globe (Dec. 18, 2002) and in the Toronto Star (Feb. 15, 2003). As a co-investigator on a President’s Emergency Plan for AIDS Relief (PEPFAR) funded project to build nursing capacity in the context of HIV/AIDS in Southern Africa, Dr. Relf, in collaboration with colleagues from Botswana, Lesotho, Malawi, South Africa, Swaziland, and Zimbabwe, published the Essential nursing competencies related to HIV and AIDS (see Journal of the Association of Nurses in AIDS, Care, 22 (Supplement 1), e5-e40). Subsequently, these competencies have been adapted to the context of HIV/AIDS nursing practice in Canada and Thailand. He has also conducted a national practice validation study to understand the entry-level competencies required of primary care nurse practitioners providing HIV specialty care (JANAC, 2016).
Dr. Relf’s research has been funded by the American Nurses Foundation; Sigma Theta Tau International; The Special Projects of National Significance, HIV-AIDS Bureau, Health Resources and Services Administration, U. S. Department of Health and Human Services; the National Institutes of Nursing Research/National Institutes of Health; the Fogarty International Center/National Institutes of Health; and the President’s Emergency Plan for AIDS Relief.
Dr. Relf is an Advanced HIV/AIDS Certified Registered Nurse (AACRN), a certified adult clinical nurse specialist (ACNS-BC), and certified nurse educator (CNE). He was recognized by the Association of Nurses in AIDS Care with the Frank Lamendola Achievement Award for Nursing Leadership in HIV Care in 2003 and the Spirit of Nursing Award for mentoring in 2006. He was selected for Fellowship into the American Academy of Nursing in 2008 and was the co-chair of the Emerging and Infectious Diseases Expert Panel from 2008 - 2010. In 2019, he was selected for Fellowship into the Academy of Nursing Education of the National League for Nursing.
Prior to joining DUSON in 2008, Dr. Relf was the Chair of the Department of Nursing at Georgetown University (2001 – 2008) and the Associate Medical Administrator/Director of Nursing and Clinical Support Services at Whitman-Walker Clinic (1999 – 2001). He earned his BS with a major in nursing from South Dakota University, his MS in nursing administration in healthcare services from Georgetown University, and his PhD in nursing from Johns Hopkins University.
David Brian Goldston
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