Improvements in Retention in Care and HIV Viral Suppression Among Persons with HIV and Comorbid Mental Health Conditions: Patient-Centered HIV Care Model

The Association of Mental Health and Substance Use With Retention in HIV Care Among Black Women in Washington, District of Columbia

BACKGROUND

Black women with HIV are impacted by mental health and substance use disorders alongside barriers to care. The impact of these disorders on retention in care, a crucial step of the HIV care continuum, has not been well-studied. We examined the association between these disorders and retention in care over a 2-year period.

METHODS

Data from January 1, 2011, to June 30, 2019, were obtained from the DC Cohort, an observational HIV study in Washington, District of Columbia. We examined the associations between mental health (i.e., mood-related or trauma-related) or substance use disorders, separately, on not being retained in HIV care over a 2-year interval post-enrollment among non-Hispanic Black women with HIV. Multivariate logistic regression with adjusted odds ratios (aORs) for sociodemographic and clinical variables was used to quantify the association of 1) having a confirmed mental health or substance use disorder and 2) not being retained in care.

RESULTS

Among the 2,181 women in this analysis, 690 (31.64%) were not retained in care. The prevalence of a mood-related disorder (39.84%) was higher compared with a substance use (16.19%) or trauma-related disorder (7.75%). Age per a 10-year increase (aOR 0.87; confidence interval [CI] 0.80, 0.94) and a mood-related disorder diagnosis (aOR 0.72; CI: 0.59, 0.88) were inversely associated with not being retained in care.

CONCLUSION

Mood-related disorders were prevalent among Black women with HIV in Washington, District of Columbia, but were not associated with worse retention in care. Future studies should examine key facilitators for Black women with HIV and coexisting mood-related disorders and how they impact retention in care.

Systematic literature review of the impact of psychiatric pharmacists

Introduction

Pharmacists focusing on psychotropic medication management and practicing across a wide variety of healthcare settings have significantly improved patient-level outcomes. The Systematic Literature Review Committee of the American Association of Psychiatric Pharmacists was tasked with compiling a comprehensive database of primary literature highlighting the impact of psychiatric pharmacists on patient-level outcomes.

Methods

A systematic search of literature published from January 1, 1961, to December 31, 2022, was conducted using PubMed and search terms based on a prior American Association of Psychiatric Pharmacists literature review. Publications describing patient-level outcome results associated with pharmacist provision of care in psychiatric/neurologic settings and/or in relation to psychotropic medications were included. The search excluded articles for which there was no pharmacist intervention, no psychiatric disorder treatment, no clinical outcomes, no original research, no access to full text, and/or no English-language version.

Results

A total of 4270 articles were reviewed via PubMed, with 4072 articles excluded based on title, abstract, and/or full text in the initial pass and 208 articles selected for inclusion. A secondary full-text review excluded 11 additional articles, and 5 excluded articles were ultimately included based on a secondary review, for a final total of 202 articles meeting the inclusion criteria. A comprehensive database of these articles was compiled, including details on their study designs and outcomes.

Discussion

The articles included in the final database had a wide range of heterogeneity. While the overall impact of psychiatric pharmacists was positive, the study variability highlights the need for future publications to have more consistent, standardized outcomes with stronger study designs.

The impact of cash incentives on mental health among adults initiating antiretroviral therapy in Tanzania

Mental illness is prevalent among people living with HIV (PLHIV) and hinders engagement in HIV care. While financial incentives are effective at improving mental health and retention in care, the specific effect of such incentives on the mental health of PLHIV lacks quantifiable evidence. We evaluated the impact of a three-arm randomized controlled trial of a financial incentive program on the mental health of adult antiretroviral therapy (ART) initiates in Tanzania. Participants were randomized 1:1:1 into one of two cash incentive (combined; provided monthly conditional on clinic attendance) or the control arm. We measured the prevalence of emotional distress, depression, and anxiety via a difference-in-differences model which quantifies changes in the outcomes by arm over time. Baseline prevalence of emotional distress, depression, and anxiety among the 530 participants (346 intervention, 184 control) was 23.8%, 26.6%, and 19.8%, respectively. The prevalence of these outcomes decreased substantially over the study period; additional benefit of the cash incentives was not detected. In conclusion, poor mental health was common although the prevalence declined rapidly during the first six months on ART. The cash incentives did not increase these improvements, however they may have indirect benefit by motivating early linkage to and retention in care.Clinical Trial Number: NCT03341556.

The Characteristics and HIV-Related Outcomes of People Living with Co-occurring HIV and Mental Health Conditions in the United States: A Systematic Review of Literature from 2016 to 2021

Considering advances in HIV prevention and treatment, jurisdictional efforts to end the HIV/AIDS epidemic, and reduced stigma towards people living with HIV infection and mental health conditions, the authors systematically reviewed studies published between 2016 and 2021 and identified 45 studies that met the eligibility criteria. The review found that stigma towards mental health conditions still acts as a barrier to accessing HIV treatment, which impacts treatment outcomes. Additionally, social determinants of health, such as housing instability and poverty, appear to impact mental health and, therefore, HIV-related outcomes. The review also highlighted the mutually reinforcing effects of HIV, mental health, and substance use conditions, providing valuable insights into the syndemic effects of these co-occurring conditions. Overall, the review highlights the need to address stigma and social determinants of health in HIV prevention and treatment efforts and to integrate mental health services into HIV care to improve outcomes for people living with both HIV and mental health conditions.

HIV viral load suppression among people with mental disorders at two urban HIV clinics in Uganda: a parallel convergent mixed methods study using the social ecological model

BACKGROUND

Uganda adopted and implemented the Universal Test and Treat (UTT) guidelines in 2017, which require HIV-infected persons to be initiated on antiretroviral therapy (ART) at any CD4 + cell count, and to be routinely monitored for viral load to assess response to ART. However, there is paucity of data on viral load suppression (VLS) among people living with HIV (PLHIV) with mental disorders. We conducted a parallel convergent mixed methods study to determine HIV VLS among people with a mental disorder and explored the socio-cultural determinants of VLS at Butabika hospital and Mulago (ISS) HIV Clinics in Uganda.

METHODS

We conducted a retrospective medical records review; seven key informant interviews (KII) among purposively selected healthcare providers and 12 in-depth interviews (IDI) among clinically stable PLHIV with a mental disorder. Data was collected on demographics, mental disorder, ART, viral load status, social support, stigma, and disclosure of HIV status. Quantitative data was analysed using descriptive statistics and modified Poisson regression, while Inductive thematic analysis was used for the qualitative data.

RESULTS

Of the 240 PLHIV with a mental disorder who were enrolled, 161 (67.1%) were female with mean age 38.9 (± 11.2) years. Overall, 88.8% (95% Cl: 84.0 - 92.2%) achieved VLS. Age (aPR = 1.00, 95%Cl = 1.00-1.00), male gender (aPR = 0.90, 95%Cl = 0.82-0.98), divorced (aPR = 0.88, 95%Cl = 0.82-0.94), widowed (aPR = 0.84, 95%Cl = 0.83-0.86), baseline CD4 count < 200 (aPR = 0.89, 95%Cl = 0.85-0.94), psychotic mental disorders (aPR = 1.11; 95%CI = 1.08-1.13) and fair (85-94%) ART adherence level (aPR = 0.69, 95%Cl = 0.55-0.87) and TDF/3TC/DTG (aPR = 0.92; 95%CI = 0.91-0.94) were associated with HIV VLS. Social support from family members, knowledge of impact of negative thoughts on VLS, fear of breaking up with partners and compassionate healthcare providers positively influenced VLS. Stigma and discrimination from the community, self-perceived stigma hindering social relations, socio-economic challenges and psychiatric drug stock-outs negatively affected VLS.

CONCLUSION AND RECOMMENDATIONS

HIV VLS among PLHIV with mental disorders at institutions that provide integrated HIV and mental health care is still below the UNAIDS 95% target. Health promotion messaging focusing on benefits of VLS and countering stigma to create a safe environment; and active involvement of family members in care could improve HIV treatment outcomes for PLHIV with mental disorders.

Prioritization of Evidence-Based and Evidence-Informed Interventions for Retention in Medical Care for Persons with HIV

Up to 50% of those diagnosed with HIV in the U.S. are not retained in medical care. Care retention provides opportunity to monitor benefits of HIV therapy and enable viral suppression. To increase retention, there is a need to prioritize best practices appropriate for translation and dissemination for real-world implementation. Eighteen interventions from CDC's Compendium of Evidence-Based Interventions were scored using the RE-AIM framework to determine those most suitable for dissemination. A CDC Division of HIV Prevention workgroup developed a RE-AIM scale with emphasis on the Implementation and Maintenance dimensions and less emphasis on the Efficacy dimension since all 18 interventions were already identified as evidence-based or evidence-informed. Raters referenced primary efficacy publications and scores were averaged for a ranked RE-AIM score for interventions. Of 18 interventions, four included care linkage and 7 included viral suppression outcomes. Interventions received between 20.6 and 35.3 points (45 maximum). Scores were converted into a percentage of the total possible with ranges between 45.8 and 78.4%. Top four interventions were ARTAS (78.4%); Routine Screening for HIV (RUSH) (73.2%); Optn4Life (67.4%) and Virology Fast Track (65.9%). All four scored high on Implementation and Maintenance dimensions. Select items within the scale were applicable to health equity, covering topics such as reaching under-served focus populations and acceptability to that population. Navigation-enhanced Case Management (NAV) scored highest on the health equity subscale. RE-AIM prioritization scores will inform dissemination and translation efforts, help clinical staff select feasible interventions for implementation, and support sustainability for those interventions.

HIV viral load suppression among people with mental disorders at two urban HIV Clinics in Uganda: a parallel convergent mixed methods study using the Social Ecological Model

Background Uganda adopted and implemented the Universal Test and Treat (UTT) guidelines in 2017, which require HIV-infected persons to be initiated on antiretroviral therapy (ART) at any CD4 + cell count, and to be routinely monitored for viral load to assess response to ART. However, there is paucity of data on viral load suppression (VLS) among people living with HIV (PLHIV) with mental disorders. We conducted a parallel convergent mixed methods study to determine HIV VLS among people with a mental disorder and explored the socio-cultural determinants of VLS at Butabika hospital and Mulago (ISS) HIV Clinics in Uganda. Methods We conducted a retrospective medical records review; seven key informant interviews (KII) among purposively selected healthcare providers and 12 in-depth interviews (IDI) among clinically stable PLHIV with a mental disorder. Data was collected on demographics, mental disorder, ART, viral load status, social support, stigma, and disclosure of HIV status. Quantitative data was analysed using descriptive statistics and modified Poisson regression, while Inductive thematic analysis was used for the qualitative data. Results Of the 240 PLHIV with a mental disorder who were enrolled, 161 (67.1%) were female with mean age 38.9 (± 11.2) years. Overall, 88.8% (95% Cl: 84.0% - 92.2%) achieved VLS. Age (aPR = 1.01, 95%Cl = 1.00-1.01), male gender (aPR = 0.95, 95%Cl = 0.95-0.95), divorced (aPR = 0.89, 95%Cl = 0.87-0.91), widowed (aPR = 0.84, 95%Cl = 0.79-0.90), baseline CD4 count < 200 (aPR = 0.89, 95%Cl = 0.82-0.95), and fair (85-94%) ART adherence level (aPR = 0.68, (95%Cl = 0.54-0.87) were associated with HIV VLS. Social support from family members, knowledge of impact of negative thoughts on VLS, fear of breaking up with partners and compassionate healthcare providers positively influenced VLS. Stigma and discrimination from the community, self-perceived stigma hindering social relations, socio-economic challenges and psychiatric drug stock-outs negatively affected VLS. Conclusion and recommendations HIV VLS among PLHIV with mental disorders at institutions that provide integrated HIV and mental health care is still below the UNAIDS 95% target. Health promotion messaging focusing on benefits of VLS and countering stigma to create a safe environment; and active involvement of family members in care could improve HIV treatment outcomes for PLHIV with mental disorders.

Association of mental health symptoms on HIV care outcomes and retention in treatment

OBJECTIVE

The purpose was to examine associations between HIV care engagement and mental health symptoms among persons living with HIV (PLWH) receiving ART. This study builds upon previous findings indicating a significant association between mental health and retention in HIV care,¹ while also advancing the literature by examining the impact of substance use on this link, as well as potential bidirectional associations.

METHOD

Participants of the current study were 493 patients who engaged in care and received antiviral therapy (ART) from Infectious Disease physicians between 2017 and 2019 in a large academic medical center.

RESULTS

Results from hierarchical regression analyses revealed that patients who missed more days of ART medication had higher depressive symptoms, even when accounting for the effect of demographic variables and alcohol use. Further, depressive symptoms predicted significant variance in number of "no show" visits, but was not individually predictive of ""no show"" visits beyond the effect of other HIV care outcomes (e.g., number of days of medication missed).

CONCLUSION

Findings reflect linkages among HIV treatment adherence, mental health, and substance use, and highlight the need to target mental health symptoms to improve outcomes among PLWH and prevent HIV transmission.

Patient-Identified Markers of Quality Care: Improving HIV Service Delivery for Older African Americans

BACKGROUND

Over 50% of new AIDS/HIV diagnoses are older adults and disproportionately African American people. Longstanding health inequities, driven by the enduring nature of systemic racism, pose challenges to obtaining optimal HIV services. Patient experiences and identities shape the health care experience, yet patient voices are often minimized, including their assessment of quality HIV care. Understanding these markers of care, including facilitators of and barriers to care and engagement, may help enhance the patient voice, potentially improving service delivery and eradicating HIV healthcare disparities.

METHOD

Using a convergent mixed method design, our study identifies patient-identified markers of quality care among older African Americans (N = 35). Measurements of global stress, HIV stigma, and engagement in care were collected, and in-depth qualitative interviews explored the symbols of quality care as well as facilitators of and barriers to care.

RESULTS

We identified widespread participant awareness and recognition of quality care, the detection of facilitators and barriers across individual, clinic, and community levels. Facilitators of care include diet, health, relationships, community support, and compassionate HIV care. Barriers to care include health comorbidities, economic, food, and housing insecurity, lack of transportation, and structural racism.

CONCLUSION

Our findings illuminate how the prominence of barriers to care often uproot facilitators of care, creating impediments to HIV service delivery as patients transition through the HIV care continuum. We offer implications for practice and policy, as well as recommendations for reducing structural barriers to care by enhancing the patient voice and for aligning services toward compassionate and inclusive care.

Addressing Women’s Needs with Human Immunodeficiency Virus (HIV) and Enhancing the Visibility of Pharmacists in the Public Health Arena

Human Immunodeficiency Virus (HIV) continues to have a staggering effect on women’s lives in the United States (U.S.). Women Living With HIV (WLWH) face many challenges, such as mental health disorders, compared to their male counterparts. These diagnoses make women more disproportionally affected, and meaningful healthcare interventions must address these conditions. This review has three foci: WLWH in the U.S., their access to care and staying in care once antiretroviral treatment has been initiated, coping with mental health, and the role of the U.S. pharmacists in access to the treatment. Pharmacists are the most easily accessible healthcare profession in the U.S. For example, 93% of American customers live within 5 miles of a community pharmacy. Pharmacists are the last healthcare provider with whom the patient interacts before a medication is dispensed; thus, they are in an ideal position to intervene. Engaging pharmacists to provide care for patients with chronic disease states such as HIV has resulted in positive outcomes. Although there are global and U.S. studies that emphasize the role of pharmacists in directing care for persons living with HIV, there is a lack of studies conducted about the role of pharmacists in managing mental health. Future research must address WLWH and mental health conditions to develop targeted interventions from an interdisciplinary team perspective.

Preferences of Young Black Gay, Bisexual, and Other Men Who Have Sex with Men Regarding Integration of HIV and Mental Health Care Services

Optimization of mental health service use is critical to HIV care engagement among young Black gay, bisexual, and other men who have sex with men (YB-GBMSM). Clinic-level interventions to integrate HIV and mental health services have been proposed; however, patient perspectives on such care models are often lacking. We conducted a mixed-methods study consisting of surveys (N = 100) and qualitative in-depth interviews (n = 15) with YB-GBMSM recruited from two Ryan White-funded HIV clinics in Atlanta, Georgia. Most participants (70%) agreed that integration of HIV and mental health services was beneficial to them. Thirty-six percent (36%) desired a higher level of integration than what they perceived was currently available in their clinic setting, 51% believed their clinic was already optimally integrated, and 13% preferred less integration. In the qualitative interviews, participants discussed their support for potential integration strategies such as training HIV providers to prescribe antidepressants, closer in-clinic proximity of HIV and mental health providers, and use of patient navigators to help patients access mental health care and remind them of appointments. Perceived benefits of care integration included easier access to mental health services, enhanced overall well-being, and improved HIV care engagement. In summary, YB-GBMSM were supportive of integrating HIV and mental health services, with varying individual preferences regarding the degree and operationalization of this integration. Improving integration of mental health and HIV services, and tailoring modes of service delivery to individual preferences, has the potential to improve both general well-being and HIV care engagement in this high priority population.

The Prevalence and Negative Impacts of Substance Use Disorders among People with HIV in the United States: A Real-Time Delphi Survey of Key Stakeholders

Although HIV and substance use disorders (SUDs) constitute a health syndemic, no research to date has examined the perceived negative impacts of different SUDs for people with HIV (PWH). In May 2019, 643 stakeholders in the U.S., representing clients of AIDS service organizations (ASOs), ASO staff, and HIV/AIDS Planning Council members, participated in an innovative Stakeholder-Engaged Real-Time Delphi (SE-RTD) survey focused on the prevalence and individual-level negative impact of five SUDs for PWH. The SE-RTD method has advantages over conventional survey methods by efficiently sharing information, thereby reducing the likelihood that between-group differences are simply due to lack of information, knowledge, and/or understanding. The population-level negative impacts were calculated by weighting each SUD's individual-level negative impact on indicators of the HIV Care Continuum and other important areas of life by the perceived prevalence of each SUD. Overall, we found these SUDs to have the greatest population-level negative impact scores (possible range 0-24): alcohol use disorder (population-level negative impact = 6.9; perceived prevalence = 41.9%), methamphetamine use disorder (population-level negative impact = 6.5; perceived prevalence = 3.2%), and opioid use disorder (population-level negative impact = 6.4; perceived prevalence = 34.6%). Beyond further demonstration of the need to better integrate SUD services within HIV settings, our findings may help inform how finite funding is allocated for addressing the HIV-SUD syndemic within the U.S. Based on our findings, such future efforts should prioritize the integration of evidence-based treatments that help address use disorders for alcohol, methamphetamine, and opioids.

African American/Black and Latino Adults with Detectable HIV Viral Load Evidence Substantial Risk for Polysubstance Substance Use and Co-occurring Problems: A Latent Class Analysis

Substance use problems are highly prevalent among persons living with (PLWH) in the United States and serve as serious barriers to engagement in HIV care. Yet, in contrast to studies of single substances, little is known about patterns of polysubstance use in this population. Moreover, other risk factors (e.g., financial hardship, incarceration, homelessness, and mental health distress) are also prevalent and complicate HIV management. The present study drew on a cross-sectional survey with African American/Black and Latino (AABL) adult PLWH from low socioeconomic status backgrounds in New York City who were insufficiently engaged in HIV care and evidenced detectable HIV viral load (N = 512). We used latent class analysis (LCA) to explore patterns of polysubstance use and their relationships to financial hardship, incarceration, homelessness, and mental health. LCA yielded three substance use classes: Class 1, a high polysubstance use/high-risk substance use class (9%); Class 2, a polysubstance use/moderate substance use risk class (18%); and Class 3, a moderate polysubstance use/moderate-to-low-risk substance use class (74%). Mental health symptoms were prevalent in all classes, but Class 1 had greater mental health distress than the other two classes. Current homelessness was more prevalent in Classes 1 and 2. We cannot end the HIV epidemic without engaging and treating AABL PLWH who have serious barriers to engagement along the HIV care continuum, and who evidence polysubstance use along with co-occurring risk factors. Clinical settings can develop outreach and engagement approaches to bring this subpopulation of PLWH into care settings, and further, specialized services are needed to successfully screen, treat, and retain them.