1. HIV Beyond 101 I. Jean Davis, PhD, DC, PA, AAHIVS Assistant Professor, Dept. Internal Medicine Charles Drew University of Medicine and Science University of California, Los Angeles Co-Principal Investigator & Director, Pacific and National Minority AIDS Education & Training Centers March 4, 2009

2. HIV & Mental Health: A Complex Issue Poor Medical and/or Psychosocial Outcomes HIV  Mental IllnessMental Illness  HIV Mental Illness  HIV  Mental illness

3. HIV & Mental Health Individuals who are HIV-infected often experience psychosocial and medical challenges such as: social isolation depression traumatic life events medication side effects comorbid illnesses

4. HIV & Effects on CNS The infection itself has direct effects on the central nervous system, causing: neuropsychiatric complications depression mania cognitive disorder frank dementia (often in combination)

5. HIV & Mental Health Individuals with mental illnesses are more at risk for HIV and AIDS due to: –disadvantaged social status and poverty –higher rates of substance abuse –homelessness/unstable housing Individuals with serious chronic mental illnesses in US have a high seroprevalence of HIV (5–7%)

6. HIV & Mental Health Availability of more effective HIV treatments has reduced mortality  more people living with HIV in US, as incidence of new cases decreases Despite advances in the treatment of HIV, there continues to be unexplained variability in the course of this disease Psychosocial factors, such as chronic depression and stressful events, can affect clinical and immunological progression of HIV/AIDS, even with decreasing prevalence of opportunistic infections (don’t fully understand biological mechanisms)

7. HIV-infected patients experience significantly more stress than the general population Some stress-related psychiatric disorders are commonly undetected and untreated in HIV health care settings –PTSD: 30-50% prevalence; more than ½ untreated –Acute stress disorder: maybe 30% prevalence –Depression Depressive symptoms highly prevalent among people living with HIV/AIDS –especially among women who are infected

8. HIV-infected patients experience significantly more stress than the general population In a national probability sample of HIV-positive men and women in the USA, the 1-year prevalence of major depression was 36% and that of generalized anxiety disorder was 16% (5 & 8x more than the general population) A large cross-cultural case control study found that rates of depressive disorders and depression symptoms were higher in symptomatic HIV-positive people than non- symptomatic and non-infected in Bangkok, Kinshasa, Nairobi and Sao Paulo

9. HIV-infected patients experience significantly more stress than the general population In one study of 210 HIV-infected patients in two county-based HIV primary care clinics in CA: 38% had depression 34% had PTSD 43% had Acute Stress Disorder 38% had 2 or more disorders 20% had all met criteria for all 3 diagnoses Women had more ASD than men African Americans and white non-Latino patients were more likely to have ASD than Latinos or other patients 43% of those with at least 1 diagnosis were not receiving concurrent mental health care treatment

10. Women with HIV more prone to emotional distress than men with HIV Factors associated with emotional distress and mental health problems in women: Younger age, more social conflict, less social support, lower perception of health, and more HIV worry were associated with higher depressive symptom scores Factors most often affecting various mood states included public housing, unemployment, social conflict, and worry about having HIV

11. Psychiatric outpatients & Sexually Transmitted Infections (STIs) In one study of 464 psychiatric outpatients: 38% reported a lifetime history of one or more STIs –Patients with a lifetime STI history were more knowledgeable about HIV, expressed stronger intentions to use condoms, and perceived themselves to be at greater risk for HIV BUT –Those with a past STI were also more likely to report sex with multiple partners and reported more frequent unprotected sex in the past 3 months

12. Summary Important to understand relationship between mental health and HIV in order to reduce the number of persons affected by the epidemic (by addressing mental health), and to improve the mental health and quality of life of those who are HIV infected. Important to understand the behavioral mechanisms associated with HIV disease progression and how they may mediate the impact of psychosocial factors on disease progression Interventions for psychiatric conditions will lead to improved healthcare outcomes for patients with HIV/AIDS and mental health disorders. –Patients with HIV/AIDS and depression who received antidepressants were more adherent to antiretroviral treatment than those who did not receive antidepressant medication

13. What can be done to address the problems? Primary healthcare of patients with HIV/AIDS could be improved by more regular use of tools to routinely screen and diagnose mental health disorders related to traumatic life events Need for STI/HIV risk reduction interventions in psychiatric settings, particularly for patients with high-risk profiles Mental Health Services need to become an integral part of HIV care Need more information and better dissemination of information about what psychological and psychiatric treatments might be beneficial for HIV-infected persons presenting with depression, past history of trauma and Post Traumatic Stress Disorder

14. “No health without mental health” Mental disorders increase risk for communicable and non-communicable diseases Many health conditions increase the risk for mental disorders Co-morbidity complicates help-seeking, diagnosis, and treatment and influences prognosis Health services are not provided equitably to people with mental disorders

15. Case Study: Howard 48 year-old male Recently released after being incarcerated for possession of cocaine No income or insurance Tested positive 8 years ago while in a methadone program Has had intermittent medical care Reports that he is staying with “a friend” Was on antiretroviral therapy while incarcerated Shows up at your clinic asking about housing What are some of the issues a case manager should explore during the psychosocial assessment?

16. Case Study: Lydia 32 year-old African American female Diagnosed with HIV following testing during a routine gynecological exam Recently separated from her husband, has 3 school- age children Employed as a nurse’s aide Living with her mother and grandmother while saving to be able to afford her “own place” What are some of the issues a case manager should explore during the psychosocial assessment?

17. References Barton, P.L., Kobayashi, J.S., Maravi, M., & Yun, L.W.H. (2005). Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients. J Acquir Immune Defic Syndr, 38, 432-438. Blank, Michael B. and Eisenberg, Marlene M. (2007) HIV and Mental Illness',Journal of Prevention & Intervention in the Community,33:1,1-4. Gore-Felton, C. & Koopman, C. (2008). Behavioral Mediation of the Relationship Between Psychosocial Factors andHIV Disease Progression. Psychosomatic Medicine 70:569–574 Israelski, D. M., Prentiss, D. E., Lubega, S., Balmas, G., Garcia, P., Muhammad, M., Cummings, S. and Koopman, C.(2007) Psychiatric co-morbidity in vulnerable populations receiving primary care for HIV/AIDS',AIDS Care,19:2,220-225 Leserman, J. (2008). Role of Depression, Stress, and Trauma in HIV Disease Progression. Psychosomatic Medicine 70:539–545 Miles, Margaret Shandor, Holditch-Davis, Diane, Pedersen, Cort, Eron Jr., Joseph J. and Schwartz, Todd (2007) Emotional Distress in African American Women with HIV', Journal of Prevention & Intervention in the Community,33:1,35-50 Prince, M., Patel, V., Saxena, S., Maj, M. Maselko, J., Phillips, M.R., Rahman, A. (2007). No health without mental health. The Lancet 370 September 8, 859-877. Vanable, Peter A., Carey, Michael P., Carey, Kate B. and Maisto, Stephen A. (2007). Differences in HIV-Related Knowledge, Attitudes, and Behavior Among Psychiatric Outpatients with and Without a History of a Sexually Transmitted Infection,Journal of Prevention & Intervention in the Community,33:1,79 — 94

18. Acknowledgement: Alison Hamilton, Ph.D. UCLA Integrated Substance Abuse Programs alisonh@ucla.edu