HIV/AIDS and Mental Health Integration: Is Something Not

Right?

Ilana Lapidos-Salaiz: MD, MPHTechnical Leadership and Research Division

Office of HIV/AIDS - USAID/Washington

AIDS 2012 - Turning the Tide Together

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.

Evidence: Correlation between HIV and 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).

Impact of HIV on MH• 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).

Continuum of care for PLHIVWHO 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

WHO pyramid Framework for optimal mix of services

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

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

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

Numbers of countries reporting national guidelines that address provision of psychological/mental health

services (N=25) Don’t know, 3

Yes, specific for

BOTH HIV- infected and

general population, 3

Yes, specific for HIV-infected, 5

No, 8

Yes, but not specific for HIV-

infected (general population), 6

Survey of 25 countries (2011):

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

COP 2012: 36 countries reviewed

34 Psychosocial services

19 Mental health

10 depression programs

6 alcohol/substance abuse programs

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: http://www.usaid.gov/our_work/global_health/aids/TechAreas/caresupport/index.html. You may also refer to PEPFAR’s care and support page: http://www.pepfar.gov/strategy/prevention_care_treatment/133360.htm.

For further information about presentation: ilapidossalaiz@usaid.gov