Addressing Mental Health Imperative to Ending the HIV Epidemic

Despite all of the medical advancements made in the fight against HIV, significant gaps remain along the HIV care continuum. One area that still needs considerable attention is mental health; mental health issues are responsible for significant comorbidity for those living with HIV, and they are more prevalent in this population compared with the general population.

In fact, among adolescents and young adults living with HIV, more than 60% of the population has some kind of mental disorder. An estimated 50% of individuals living with HIV meet criteria for one or more mental or substance use disorder, which is associated with suboptimal HIV treatment outcomes that include late antiretroviral therapy (ART) initiation and a delayed viral suppression.

At the 25th Conference on Retroviruses and Opportunistic Infections, Robert Remien, PhD, stressed in his presentation that addressing mental health is a critical component to ending the HIV epidemic and achieving the UNAIDS 90-90-90 goals.

“We know that we need to do better at all of the steps on the continuum to achieve our desired goals for better health outcomes as well as reduce incidence,” Dr. Remien said. “Integration of services to screen and manage mental health and substance use disorders into HIV care settings is a promising strategy to improve mental health and HIV treatment outcomes among people living with HIV/AIDS, including in resource-constrained settings.”

Mental illness, according to Dr. Remien, is, indeed, a risk factor for HIV acquisition. In the United States, the HIV prevalence among those with a serious mental illness (ranging from 2% to 6%) compared with the general population (0.5%) is significantly higher.

Mental health impairment contributes to increased risk behaviors, delayed or lack of HIV testing and care initiation, poor retention in care, delayed ART initiation, and poor ART adherence.

When there are comorbid disorders, and other disorders—such as mood disorders and alcohol and substance abuse—there’s a synergistic effect on HIV outcomes. Dr. Remien discussed a study that focused on 4,295 men who have sex with men (MSM) from 6 US cities, who had co-occurring conditions such as depressive symptoms, heavy alcohol use, stimulant use, polydrug use and childhood sexual abuse; the probability of staying HIV-negative decreases significantly as the number of conditions increases.

In the context of PrEP adherence, depression is associated with higher sexual risk behavior and poorer adherence, indicating that screening and treating may be key to maximizing PrEP efficacy.

Depression is associated with increased morbidity and mortality rates for those living with HIV; having a major depressive disorder (MDD) is twice as high for those without MDD. Relatively large cohorts of women have been studied over time and found that depression is associated with 2 to 3 times the risk of mortality, compared with women who do not have depressive symptoms, when on ART.

In the Women’s Interagency HIV Study (WIHS) prospective cohort (n=858), chronic depressive symptoms were associated with >3 times the hazard of mortality (women on ART) and >7 times the hazard of mortality (women not on ART) compared to those on ART with no depression.

The stigma embodied in discriminatory social structures, policy, and legislation results in a disparity between physical and mental health care services with lower accessibility, availability, and quality of services.

Integration of screening and management services into HIV care settings is a promising strategy, according to Dr. Remien, to improve mental health and HIV treatment outcomes, including resource-constrained settings.

Positive mental health is associated with improved physical health outcomes across a range of chronic illnesses. However, in addition to negative psychological responses to an HIV diagnosis, disease progression, associated stigma, and loss of social support is estimated to contribute to elevated rates of mental health problems among patients.

Treatment for mental disorders and adherence interventions has an additive effect to those with HIV, positively affecting HIV health outcomes when it comes to PrEP treatment, reducing depression and anxiety, and ultimately, increasing quality of life.

Challenges remain, specifically for meeting the high demand in resource-limited settings where HIV is most prevalent. Addressing mental health co-morbidities in the context of HIV prevention and care is essential for achieving optimal outcomes along the prevention and treatment continuum.

“We may have the biological tools to ‘end AIDS,’ however, we will not be able to achieve ‘ending the epidemic’ (EtE) goals if we do not address mental health co-morbidities among our most vulnerable populations,” Dr. Remien concluded. "Integrating mental health assessment and treatment into HIV care should be routine and is essential to achieving “90 90 90 and EtE goals.”