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

2. 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

3. 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

4. Correlation between MH and HIV/AIDS
Premorbid Co-morbid
Psychopathology Psychopathology
Prevention Treatment and Care
General Population MH SA
PLHIV
Limited access to care
Low adherence to ART
Higher mortality
High risk behavior

5. 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

6. Dimensions of Mental Health
Biomedical
Behavioral
Psychosocial

7. 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

8. 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

9. 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

10. MH and Clinical Stages of progression of HIV/AIDS
Time (Years)
0-1
1-2
2-10
3-15
Death
HIV Stage
At Infection I
Initial Diagnosis II
Asymptomatic Phase
III & IV
AIDS
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
HIV
Dementia
Psychosis
Mania
Seizures

11. 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):
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):

12. 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

13. 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 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),
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):

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

15. SA and HIV/AIDS Infection
Newly diagnosed HIV/AIDS cases resulting from IDU in US in 2005
Whites
Blacks
Hispanics 50
Females 40
Males* 33 30 30 30 29
*Includes MSM who are IDUs. 24
New Cases of HIV/AIDS (%) 20 17 10
Centers for Disease Control and Prevention. Available at: resources/reports/2005report. Accessed January 9, 2008

16. MH and Adherence to ART Attribute % of Non-adherence to ART
Active alcohol abuse
Active injection drug use
Homelessness
Depression
History of injection drug use
History of alcohol abuse
Motherhood of small children
Lower educational level
Lower income level
Minority race
Stone V, et al. Curr HIV/AIDS Rep. 2005;2:

17. Depression and Mortality in PLHIV
HIV-Related Mortality
1.0
0.9
Cumulative Survival
0.8
Limited depression
Intermittent depression
Study assessed association of depressive symptoms with HIV-related mortality and decline in CD4+ cell counts in HERS cohort (N = 765)
Depression (CES-D) defined as limited, intermittent, or chronic
Multivariate analysis: increased RR of mortality in women with chronic depressive symptoms (2.0; 95% CI: ) vs those with limited or no symptoms
Mortality in patients with CD4+ < 200
Chronic depression: 54%( RR: 4.3; 95% CI: ) vs limited depression
Intermittent depression: 48% (RR: 3.5; 95% CI: ) vs limited depression
Limited depression: 21%
Chronic depression
0.7 1 2 3 4 5 6 7
Total Time in Study (Yrs)
Ickovics JR, et al. JAMA. 2001;285: 17

18. 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
Educational sessions,
stigma reduction,
health promotion
campaigns, home
visits, focus groups
Supportive counseling, peer
support groups, coping,
stress management,
life skills training
Psychotherapeutic or pharmacologic treatment
modalities
WHO Framework recognizes the need for multiple levels of MHS delivery in HIV/AIDS interventions. A balance of community based and hospital based services has been shown to be the most effective form of comprehensive mental health care
Trained mental health
professionals or primary
care physicians
Trained counselor or peer
support volunteer
Trained community
health care workers,
social workers,
CBOs, NGOs and FBOs

19. 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

20. Challenges and Opportunities : Integrating Mental Health into HIV/AIDS care
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 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 psychosocial needs for PLHIV
Research and pilot projects to inform programmatic interventions

21. Outcome of MH Interventions in Prevention and Treatment of PLHIV
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.

22. 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):

23. 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

24. Conclusion Reduce new infection and onward transmission
Better health outcome for PLHIV
Synergistic opportunities
Actively addressing mental healthhas the potential to reduce behaviors that lead to risky sexual behavior and HIV transmission, while also positively impacting the health of those living with HIV/AIDS
Integration of mental health services into existing HIV/AIDS programs could provide a viable method to capitalize on existing infrastructure while synergistically improving health outcomes

25. Thank you