Integrating Mental health services in HIV Care programs the by pp00pp


  PREVENTION: The Time has
   Come for a More Holistic

        Jude Awuba, MPH,CHES
Technical Leadership & Research Division
    of HIV/AIDS, USAID/Washington

• To review key mental health (MH) issues in
  the continuum of care for people living with
• 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
• 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
• Syndemic occurrence of MH, substance abuse
  (SA) and HIV
             Correlation between MH and HIV/AIDS
     Premorbid               Co-morbid
     Psychopathology         Psychopathology

                                        MH     •Limited access to
                  MH                                  care
                                                •Low adherence
 General                    PLHIV                    to ART
Population                                     •Higher mortality
                                                   •High risk
                   SA                              behavior

         Prevention           Treatment and Care
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
• 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
  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           0-1              1-2             2-10          3-15         Death

 HIV              0                I             II           III & IV    After Death
Stage       At Infection        Initial     Asymptomatic        AIDS
                              Diagnosis        Phase

Mental    •Substance        •Acute stress   •Depression    •HIV          •Post-
Health    Abuse             reactions       •Substance     Dementia      Traumatic
          •Post-Traumatic   •Adjustment     abuse          •Delirium     Stress
          Stress Disorder   disorders       •Anxiety       •Psychosis    Disorder
                            •Panic          disorders      •Mania
                            disorders       •Personality   •Depression
                            •Delirium       changes        •Seizures
                            •Suicide        •Suicide
          Global Prevalence of MH in PLHIV
• 10% of HIV-infected patients worldwide are
• 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
     Uganda                                            PLHIV in a clinic in                              HIV Dementia- 47%                                  5.4%
                                                       Western Uganda
     South Africa                                      Random sample of MH disoder-43.7%                                                                  18.1%
                                                       900 PLHIV

     Kenya                                             PLHIV attending                                   Alcohol Abuse- 55%                               7.1%
                                                       clinic in Western

Nakasujja, N., Musisi, S., Robertson, K., Wong, M., Sacktor, N. & Ronald, A. (2005) Human immunodeficiency virus neurological
complications: 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 • Clinical Outcomes
   – Higher rates of               – HIV Dementia
     transmission                  – Rapid AIDS progression
                                   – Higher mortality
• Treatment and Care
   – Limited access to care
   – Low uptake and
     adherence of ART
   – High failure rate to
     routine checks
                                       SA and HIV/AIDS Infection

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

                                       50   Whites      Blacks                    Hispanics
           New Cases of HIV/AIDS (%)

                                       40                                                                 Females
                                            33                                                            Males*
                                       30                    30                   29      30              *Includes MSM
                                                      24                                                  who are IDUs.

                                       20        17


         Centers for Disease Control and Prevention. Available at:
         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

                                                       HIV-Related Mortality
          Cumulative Survival


                                          Limited depression
                                          Intermittent depression
                                          Chronic depression
                                      0   1   2    3   4    5    6    7
                                          Total Time in Study (Yrs)

Ickovics JR, et al. JAMA. 2001;285:1466-1474.
          Adapted WHO Framework for
           Integrating MHS in HIV/AIDS

Level I: Treatment of mental   Level II: Supportive behavioral    Level III: Community
          disorder             interventions for at risk group      mobilization and

                                                                 Educational sessions,
                               Supportive counseling, peer       stigma reduction,
    Psychotherapeutic or
                               support groups, coping,           health promotion
  pharmacologic treatment
                               stress management,                campaigns, home
                               life skills training              visits, focus groups

 Trained mental health         Trained counselor or peer
 professionals or primary      support volunteer                 Trained community
 care physicians                                                 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
• 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

Stigma associated with MH and HIV           Community mobilization and advocacy
                                            Treatment 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          Research and pilot projects to inform
psychosocial needs for PLHIV                programmatic interventions
     Outcome of MH Interventions in
    Prevention and Treatment of PLHIV
                                                                       P ris on Needle E x c hang e
                                                                             P rog ram for ID U


                                           % of HIV trans mis s ion
                                                                         5%           0%

                                                                      P NE P               0%
                                                                      NO NE              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

• Reduce new infection and onward

• Better health outcome for PLHIV

• Synergistic opportunities
Thank you

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