Topic: Addressing the mental health of people living with HIV as a means to optimize HIV treatment.
Background: Globally, mental health and neurological disorders continue to count as a top-five risk factor for disability and mortality. In people living with HIV (PLWH), the most rigorous and nationally representative study to date found that up to 48% of PLWH met criteria for a depressive or anxiety disorder and/or were using illicit drugs or engaging in problematic drinking. Mental health problems and substance use directly impact the management of HIV and clinical outcomes.
Intervention: Successful management of HIV and prevention of forward transmission requires the achievement of viral suppression via good antiretroviral therapy (ART) adherence. But high-quality meta-analytic data show ART adherence is impaired by psychological disorders that either diminish motivation for self-care or lead to forgetfulness. An abundance of evidence shows the efficacy of HIV adherence-promoting and treatment interventions for mental health and HIV adherence issues simultaneously. Advancements in new ART and improvements in the epidemic as a whole have not led to better mental health or reductions in the prevalence of substance use. It remains a challenge to treat ongoing mental health problems that affect over 1 in 3 PLWH.
Solution: Brief and adaptable interventions to treat mental health problems and promote adherence have been studied in HIV care, but have not been adopted or fully integrated. Multisite trials of integrated treatment for depression within primary care show faster times to first mental health care visit, greater number of visits and better appointment attendance. One solution is to identify the reasons why the adherence-promoting interventions are not better integrated within HIV care settings given the burden of the problem, and the because there are clear, low-cost and readily available interventions for problems of medication and appointment attendance.
Utilization: Many people living with HIV engage in HIV care well, but severely underutilize psychological treatment services. A key challenge is harness the infrastructure and resources given to HIV care to also address mental health problems that directly impede on the management of the disease. Further, another challenge is identifying personnel who can accurately screening and diagnose patients for psychological disorders, and the logistics of a streamlined “hand off” from providers to interventionist/therapist.
Benefits: There is both benefits in terms of reductions in rates of suicide, and greater disability adjusted life years gained. Further, the “treatment as prevention strategy” as a national organizing effort only succeeds when PLWH achieve viral suppression. The PLWH who are least likely to achieve viral suppression are those struggling with mental health and problematic substance use.