By Jude Awuba, MPH,CHES

Technical Leadership & Research Division of HIV/AIDS, USAID/Washington

INTEGRATING MENTAL HEALTH SERVICES INTO HIV CARE AND

PREVENTION: The Time has Come for a More Holistic

Approach

Objectives

• To review key mental health (MH) issues in the continuum of care for people living with HIV (PLHIV)

• To provide a framework for integrating mental health services into HIV/AIDS interventions

• To discuss a public health approach to addressing the co-occurrence of MH and HIV

Background

• Antiretroviral Therapy (ART) has led to a reduction of AIDS mortality

• The goal of HIV treatment and care has shifted from delaying death to achieving optimal health outcomes

• Syndemic occurrence of MH, substance abuse (SA) and HIV

Correlation between MH and HIV/AIDS

Premorbid Co-morbid Psychopathology Psychopathology

Prevention Treatment and Care

General Population

MH

SASA

MH

PLHIV

•Limited access to care

•Low adherence to ART

•Higher mortality•High risk behavior

Bi-directional Relationship Between MH and HIV/AIDS

• Mental health increases risk for HIV• HIV increases risk for mental health• Effective treatment for mental health can

decrease HIV transmission• Effective treatment of mental health can

improve outcome for PLHIV

Dimensions of Mental Health

Co-occurrence of MH and HIV/AIDS

Biomedical• Sub-cortical degeneration caused by HIV virus• Brain damage as result of opportunistic

infection• Pharmacologic effects of treatment

Co-occurrence of MH and HIV/AIDS

Behavioral • Injection drug use (IDU)—

needle sharing and trading sex for drugs

• Alcohol abuse—high risk behavior, unsafe sex and inconsistent/incorrect condom use

Co-occurrence of MH and HIV/AIDS

Psychosocial• Patients’ awareness of

the prognosis and fatal outcome of the disease

• Stigma against PLHIV• Worries and anxieties

arising from socio-economic repercussions of health status

MH and Clinical Stages of progression of HIV/AIDS

Time (Years)

0-1 1-2 2-10 3-15 Death

HIV Stage

0 At Infection

I Initial

Diagnosis

IIAsymptomatic

Phase

III & IVAIDS

After Death

Mental Health

•Substance Abuse•Post-Traumatic Stress Disorder

•Acute stress reactions•Adjustment disorders•Panic disorders•Delirium•Suicide

•Depression•Substance abuse•Anxiety disorders•Personality changes•Suicide

•HIVDementia•Delirium•Psychosis•Mania•Depression•Seizures

•Post-Traumatic Stress Disorder

Global Prevalence of MH in PLHIV

• 10% of HIV-infected patients worldwide are IDUs

• 70% patients with HIV suffer from an acute psychiatric complication during the course of the illness

• 90% of people who have recently been diagnosed with HIV infection suffer from acute stress disorder

Aceijas C, Stimson , GV., Hickman, M. Global Overview of Injection Drug Use and HIV infection among injection drug users. AIDS

2004, 19;18 (17):2295-3303

Adewuya, A.O. Afolabi, B.A, Ogundele, A O. Ajibare, and B.F Oladipo, “Psychiatric Disorders Among the HIV-Positive Population

in Nigeria: A control Study.” J , Psychosom Res 63, no (2007): 203-6.

Gaps in MHS in PLHIV

• Mental health conditions for PLHIV are under diagnosed and under treated

• In resource-limited countries:– High burden of HIV/AIDS – Limited capacity of MHS delivery

Gaps in MHS in PLHIV

Country Study Population MH Prevalence HIV/AIDS Prevalence

Uganda PLHIV in a clinic in Western Uganda

HIV Dementia- 47% 5.4%

South Africa Random sample of 900 PLHIV

MH disoder-43.7% 18.1%

Kenya PLHIV attending clinic in Western Kenya

Alcohol Abuse- 55% 7.1%

Nakasujja, N., Musisi, S., Robertson, K., Wong, M., Sacktor, N. & Ronald, A. (2005) Human immunodeficiency virus neurologicalcomplications: an overview of the Ugandan experience. Journal of Neurovirology 11(supplement 3), pp. S26–S29.Freeman, M ., Nkomo N., Karafar, Z. & Kelly K. (n.d). Factors Associated with the prevalence of mental disorder in people living with HIV/AIDS in South Africa. Aids Care, 19 (10), 1201-1209.Geetanjali , C., Seth, H., and Richmond D. Substance Abuse and Psychiatric Disorders in HIV –Positive Patients: Epidemiology and Impact on Antiretroviral Therapy. Drugs 2006;66 (6):769-789

Impact of MH on HIV/AIDS Prevention, Treatment and Care Outcomes

• Prevention– High risk behavior– Higher rates of infections– Higher rates of

transmission

• Treatment and Care– Limited access to care– Low uptake and

adherence of ART– High failure rate to

routine checks

• Clinical Outcomes– HIV Dementia– Rapid AIDS progression– Higher mortality

SA and HIV/AIDS Infection

• Newly diagnosed HIV/AIDS cases resulting from IDU in US in 2005

33

17

2429 30

0

10

20

30

40

50

30

Whites Blacks

New

Cas

es o

f HIV

/AID

S (

%)

Hispanics

FemalesMales*

*Includes MSM who are IDUs.

Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/hiv/topics/surveillance/ resources/reports/2005report. Accessed January 9, 2008

MH and Adherence to ART

• Attribute % of Non-adherence to ART• Active alcohol abuse 93.1

• Active injection drug use 92.5

• Homelessness 88.1

• Depression 69.2

• History of injection drug use 52.9

• History of alcohol abuse 43.4

• Motherhood of small children 38.1

• Lower educational level 37.0

• Lower income level 15.8

• Minority race 11.4

Stone V, et al. Curr HIV/AIDS Rep. 2005;2:189-193

Depression and Mortality in PLHIV

Ickovics JR, et al. JAMA. 2001;285:1466-1474.

HIV-Related Mortality

Total Time in Study (Yrs)

Intermittent depressionChronic depression

Limited depression

1.0

76543210

0.9

0.8

0.7

Cum

ulat

ive

Sur

viva

l

Adapted WHO Framework for Integrating MHS in HIV/AIDS

Interventions

Level I: Treatment of mental disorder

Level II: Supportive behavioral interventions for at risk group

Level III: Community mobilization and

prevention

Psychotherapeutic or pharmacologic treatment

modalities

Supportive counseling, peersupport groups, coping,stress management, life skills training

Educational sessions,stigma reduction,health promotion campaigns, homevisits, focus groups

Trained mental healthprofessionals or primarycare physicians

Trained counselor or peersupport volunteer Trained community

health care workers, social workers, CBOs, NGOs and FBOs

WHO Framework: Key Features

• Multiple levels of intervention both facility and community-based services

• Interventions are community and culturally driven to fit local conditions

• Coordination of services across multiple levels and integration with other HIV services

• Emphasis on prevention of disease and promotion of health

• Focus on communities rather than individuals

Challenges and Opportunities : Integrating Mental Health into HIV/AIDS care

CHALLENGES OPPORTUNITIES

Limited capacity of the healthcare system Integration of mental health into primary care and HIV/AIDS programming

Inadequate MH providers Pre and in-service training of primary care providers

Stigma associated with MH and HIV Community mobilization and advocacyTreatment of MH at primary care level

Fragmented healthcare system Strengthening linkages and referral system

Disease management approach Disease prevention and health promotion

Knowledge gap on mental health and psychosocial needs for PLHIV

Research and pilot projects to inform programmatic interventions

Outcome of MH Interventions in Prevention and Treatment of PLHIV

0%

34%

0%

5%

10%

15%

20%

25%

30%

35%

% o

f H

IV t

ran

sm

iss

ion

P ris on Needle E xc hang e P rog ram for IDU

P NE P 0%

NONE 34%

Moore RD., Keruly J (2004). Difference in HIV disease progression by injecting drug use in HIV-infected persons in care. J

Acquir Immune Defic Syndr 35 (1):46-51.

Outcome of MH Interventions in Prevention and Treatment of PLHIV

Source L Lourdes Y., Maravi et al, (2005). Antidepressant Treatment Improves Adherence to Antiretroviral Therapy Among Depressed HIV-infected Patients. J Acquir Immune Defic Syndr (38): 432-438

10 Reasons for Integrating MH into HIV Prevention and Treatment

• Reduce new infections• Reduce onward transmission (prevention

with positives)• Increase access to care• Increase uptake to ART• Reduce rate of loss to follow up • Increase adherence to ART• Reduce morbidity and mortality of PLHIV• Cost-effectiveness• Integrated services— two- in-one• Strengthen linkages and referral system

Conclusion

• Reduce new infection and onward transmission

• Better health outcome for PLHIV

• Synergistic opportunities

Thank you