1. 1 The relationship between the HIV, Disability and the CRPD. Charlotte McClain-Nhlapo July 26 th 2012.

2. Cross cutting issues  HIV like Disability, are not just health issues- but rather sets of complex constructs with underlying societal inequities and injustices.  The broader social and cultural context of the HIV epidemic and Disability require an understanding of the unique barriers that persons with disabilities and those living with HIV experience.

3. Stigma and Discrimination  Stigma > vulnerability to discrimination.  Discrimination can be both a cause and a consequence of human rights violations.  Requires the removal of socially constructed barriers.  Failure to provide reasonable accommodate is discrimination.

4. The intersectionality ….. 4

5. A symbiotic relationship  The HIV and AIDS international human rights framework and disability is mutually reinforcing and complementary.  The CRPD framework and HIV and AIDS is also synergistic.  Many of the attitudinal barriers are similar.

6. An inclusive approach  Takes into account human rights principles i.e. non-discrimination equality accessibility participation All contained in CRPD and reflected in all core UN human rights treaties.

7. Political Declaration on HIV and AIDS (2011)  UN General Assembly recognizes the adoption of the Convention on the Rights of Persons with Disabilities and emphasizes the need “to take into account the rights of persons with disabilities as set forth in the Convention, in particular with regard to health, education, accessibility and information, and in the formulation of our global response to HIV and AIDS.”

8. Add value of the Rights Based Approach  It is a comprehensive approach  Seeks to develop inclusive laws, policies and programming that promote inclusion in all aspects of society. That codify equality of access to a continuum of rights Protect the most vulnerable Provide for redress

9. CRPD as a tool  Art. 8 Awareness raising is an important article in the fight against AIDS for persons with disabilities.  Art. 13 Access to justice in the event that redress is being sought out  Art. 21 Freedom of expression & opinion &access to information  Art 22. Respect for privacy

10. Developing Legal Frameworks at national level  UNAIDS highlights the importance of protecting the rights of persons affected by and vulnerable to HIV through national legal frameworks.  Three areas of focus: Empowering communities to have access to justice. Ensuring respect for human rights in the context of law enforcement. Creating enabling law and policy frameworks 10

11. Let’s keep talking about inclusion- Thank you ! 11

12. HIV Infection, Disability and Mental Illness Francine Cournos, M.D. Professor of Clinical Psychiatry (in Epidemiology) Mailman School of Public Health Columbia University fc15@columbia.edu July 26, 2012

13.  This talk primarily focuses on the five mental illnesses most commonly associated with disability: depression, alcohol use disorder, schizophrenia, bipolar disorder, and drug use disorders.  This talk does not address intellectual disabilities, developmental disorders, or neurological illnesses such as epilepsy. Mental Disabilities: Focus of This Talk

14. 5 Mental Illnesses Are among the Top 10 Causes of Years Lost to Disability (YLD) Worldwide WHO, Global Burden of Disease, 2008 Update

15. Why is Mental Illness Such a Common Cause of Disability?  Mental disorders are relatively common illnesses.  In all regions of the world, neuropsychiatric conditions are the most important causes of disability, accounting for about one third of years lost to disability (YLD) among adults 15 years or older  Mental disorders often begin in childhood--about half have onset before the age of 14--creating the possibly of lives lived for many years with disability. WHO, Global Burden of Disease, 2008 Update, and other references

16. Why is Mental Illness Such a Common Cause of Disability?  Mental illnesses cause more severe disability than most medical illnesses. That makes sense: the brain is the central control center for the body.  Severe depression and acute psychosis are classified by WHO as more disabling than AIDS not on antiretroviral drugs, congestive heart failure, tuberculosis and the neurological consequences of malaria.  A person with one mental illness is at increased risk for another mental illness; co-morbidity among mental disorders is very common. WHO, Global Burden of Disease, 2008 Update, and other references

17. Why is Mental Illness Such a Common Cause of Disability?  Mental illness is undertreated due to stigma, low priority in global and country level funding; and lack of community care, trained health care workers, psychotropic medications, psychotherapy and rehabilitation.  Many people with mental illness are not in environments that assist them to function well; they may be institutionalized, homeless, ignored and/or become victims of human rights abuses. WHO, Global Burden of Disease, 2008 Update, and other references

18.  Severely limited HIV prevention services  Drug injection  High rates of unsafe sexual behavior, including those mediated by being high on alcohol or drugs  Increased sex between men in institutional settings  High rates of coerced sex  High rates of exchanging sex for essentials (like food or a place to stay) or drugs  Mental illness stigma that limits choice of sexual partners Many Factors Put People with Mental Disabilities at Risk for HIV Infection

19.  Published studies of HIV infection rates in U.S. and African Psychiatric Hospitals: South Africa27%South Africa27% Zimbabwe 24%Zimbabwe 24% Uganda18%Uganda18% United States 3-23%United States 3-23% High Rates of HIV Infection Are Found Among People Hospitalized for Severe Mental Illness High Rates of HIV Infection Are Found Among People Hospitalized for Severe Mental Illness

20. In Addition, Mental Illnesses Often Precede HIV Infection Among Most At Risk Populations u IDU: High rates of alcohol/substance use disorders and depression u MSM: Elevated rates of alcohol/substance use disorders, depression and anxiety disorders u Sex Workers: Elevated rates of addictive disorders and posttraumatic stress disorder American Psychiatric Association Practice Guidelines and other reference documents www.psych.org/aids

21.  Worldwide studies reveal that depression and alcohol/substance use disorders are associated with increased morbidity and mortality among people with HIV infection.  Contributing factors include the association of depression and/or alcohol/substance use with Failure to access HIV care and treatmentFailure to access HIV care and treatment Failure to adhere to antiretroviral treatment (ART) once it has been startedFailure to adhere to antiretroviral treatment (ART) once it has been started Prolonged time to viral suppression on ARTProlonged time to viral suppression on ART Early failure of viral suppression on ARTEarly failure of viral suppression on ART Possible direct effects on the immune systemPossible direct effects on the immune system Mental Illness Among HIV+ People: Impact on Morbidity/Mortality

22. The Good News Regarding HIV and People with Mental Disabilities The Good News Regarding HIV and People with Mental Disabilities  Treatments for mental illness compare favorably to treatments for medical illness in cost and outcome.  There are well developed guidelines for screening and treating mental illnesses in primary care and HIV care.  People with mental disabilities respond well to HIV prevention strategies and reduce their risk behaviors.  People with psychotic disorders (such as schizophrenia) are as adherent to antiretroviral treatment as the general population.  We will make great progress in upholding human rights by implementing the mental health and HIV services that have been proven to work.

23.  Integration work began in 2007 and is ongoing  From the beginning it was a partnership: The government of RwandaThe government of Rwanda Ndera Neuropsychiatric HospitalNdera Neuropsychiatric Hospital ICAP at Columbia University; PEPFAR funding; CDCICAP at Columbia University; PEPFAR funding; CDC Other stakeholders meeting in technical working groupOther stakeholders meeting in technical working group  Accomplishments: Surveying needs and resources for HIV/MH integrationSurveying needs and resources for HIV/MH integration Beginning implementation at Ndera Neuropsychiatric HospitalBeginning implementation at Ndera Neuropsychiatric Hospital Testing all consenting and capable inpatients at Ndera for HIV infection, later followed by testing of outpatientsTesting all consenting and capable inpatients at Ndera for HIV infection, later followed by testing of outpatients Case Example: Integrating HIV and Mental Health Care in Rwanda

24.  Accomplishments, con’t As of 2011 >1200 patients tested; among inpatients, HIV+ rate about 10%; lower rates among outpatients; half of infected inpatients were newly identifiedAs of 2011 >1200 patients tested; among inpatients, HIV+ rate about 10%; lower rates among outpatients; half of infected inpatients were newly identified HIV+ patients were enrolled in HIV care and treatment, usually at NderaHIV+ patients were enrolled in HIV care and treatment, usually at Ndera Implementation begins at district hospitalsImplementation begins at district hospitals Instruments selected and translated for screening patients in HIV care for mental illnessInstruments selected and translated for screening patients in HIV care for mental illness Health care providers received training in mental disorders and use of instruments.Health care providers received training in mental disorders and use of instruments. Screening implemented with referral to mental health nurses for those who screen positive for mental illnessScreening implemented with referral to mental health nurses for those who screen positive for mental illness Case Example: Integrating HIV and Mental Health Care in Rwanda

25.  Challenges Overcoming resource limitations in the areas of available mental health/health care providers, mentors, psychotropic medications, psychotherapies and alcohol/substance use treatmentsOvercoming resource limitations in the areas of available mental health/health care providers, mentors, psychotropic medications, psychotherapies and alcohol/substance use treatments Training clinicians to better distinguish between delirium and mental illnessTraining clinicians to better distinguish between delirium and mental illness Improving research/evaluation to guide implementation efforts and improve adaptation to the Rwandan context.Improving research/evaluation to guide implementation efforts and improve adaptation to the Rwandan context. Case Example: Integrating HIV and Mental Health Care in Rwanda