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HIV/AIDS and Mental Health Integration: Is Something Not Right

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1 HIV/AIDS and Mental Health Integration: Is Something Not Right
HIV/AIDS and Mental Health Integration: Is Something Not Right? Ilana Lapidos-Salaiz: MD, MPH Technical Leadership and Research Division Office of HIV/AIDS - USAID/Washington

2 ABOUT PEPFAR: Increase and build upon what works and, support countries as they work to improve the health of their own people: PEPFAR's Goals: Transition from an emergency response to promotion of sustainable country programs. Strengthen partner government capacity to lead the response to this epidemic and other health demands. Expand prevention, care, and treatment in both concentrated and generalized epidemics. Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems. Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.

3 Evidence: Correlation between HIV and MH
Impact of HIV on MH Impact of MH on HIV Mental illness may be a risk factor for HIV infection due to impaired judgment and high risk behaviors (Collins, et al. 2006; Smit el al. 2006) Psychiatric disorders such as depression have been consistently linked with lowered likelihood of receiving HAART (Fairfield, et al, 1999)), Results in poorer medication adherence (Ammassari et al., 2002; Catz, Kelly, & Bogart,2000) if untreated, greater mortality” (Cook et al., 2004; Ickovics et al., 2001) “For HIV-infected people, mental illness is a risk factor for non-adherence to antiretroviral therapy (ART) (Mellins et al., 2003). Poor mental health undermines immune functioning and can negatively influence disease progression” (Antelman et al., 2007; Ickovics et al., 2001; Mellins et al., 2003; Murphy et al., 2004 Successful treatment of depression improved adherence to ART (Dalessandro et al. 2007) and increases in CD4 counts (Horberg et al. 2008). Mental health conditions in PLHIV are under-diagnosed and under-treated (WHO 2001) “PLWHA are twice as likely to suffer from depression than the general population (Ciesla & Roberts, 2001). “In all cohorts, ART was associated with reduced anxiety, depression, and dementia. In Cape Town, 85.5% of ART patients reported ‘‘no problems’’ with depression/anxiety after 12 months on ART, from 68.4% at baseline (Jelsma et al., 2005).

4 Continuum of care for PLHIV
WHO continuum of care model proposes continuous and responsive support to PLHIV with input from different sources of formal and informal health care system… Addressing Mental health* (and psychosocial support) is a key element of the continuum of care model - a comprehensive care approach that should be addressed at all levels of care Advent of ART has resulted in PLHIV living “normal” active life but, PLHIV experience range of emotional, social, and spiritual needs throughout their life *depression among PLHIV ranges between 20-48% in high income countries (Berger et al and 70 % in LIC (Adewuya et al)

5 WHO pyramid Framework for optimal mix of services

6 Elements necessary for integrating MH services
Policy and guidelines Incorporated into broader Public Health Strategy to achieve maximum coverage and commitment Integrated into health care system – facility and community level Referral systems/networks: Linkage between facility and care linked to community on-going treatment Support for MH workers: Human resource Development - Community/Primary care training in screening and delivery of MH services Resources (including) funding Drug supply and management (adapted from Kelly and Freeman, 2005

7 Realities on the ground…
Policymakers, donors, health care leaders are burdened with competing priorities Goals targeting improved health must compete for policy attention and resources Difficult for countries to commit adequate resources to comprehensively address mental health problems in that society, including PLHIV. Countries/programs are at different stages of implementation – challenge for transition to more sustainable, country-led and owned programs Program who are in less mature stages of system development are encouraged to learn from evidence base and use best practices to scale up services in efficient and effective manner

8 Gaps in MH services: Country profile of 9 countries (2010):
Formulated mental health policy: 7 countries Formulated substance Abuse policy: 6 countries Formulated mental health program: 6 countries Adequate policy funding 2 out of 9 countries Access to services is varied: Access to free essential medication (Psychotropic drugs): Access to other basic services

9 Survey of 25 countries (2011):
Num b e r s o f c u n tries eporting na ti al g idel i es t ha ad d ess p vis io sy h l gical/me nt a lth se vi ( N=2 5 ) Do ’t kno w , 3 Y s, ifi or B O T H HI V - te pul HIV N 8 bu ot ne ), 6

10 Current USG efforts Focused on increase screening and interventions in community and primary care setting Integrate MH (depression and substance abuse) screening and treatment into HIV/AIDS (and other) services Strengthen linkage between other care and support services and mental health care (depression and alcohol abuse) Identify cost efficiencies and sustainable interventions

11 COP 2012: 36 countries reviewed
34 Psychosocial services 19 Mental health 10 depression programs 6 alcohol/substance abuse programs

12 Acknowledgments USAID and PEPFAR
Coordinating Organizations (U.S. Health and Human Services Office of Global affairs and U.S. National Institute of Mental) Anne Herleth; Thomas Kresina (SAMHSA) For further information on the HIV/AIDS Care and Support work that USAID does under the Care and Support portfolio, refer to: You may also refer to PEPFAR’s care and support page: For further information about presentation:

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