by jude awuba, mph,ches technical leadership & research division of hiv/aids, usaid/washington...
TRANSCRIPT
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