Mapping the effectiveness of integrating mental health in HIV programs: a scoping review

Schizophrenia and Retention in HIV Care Among Adults Insured Through Medicaid in the United States: A Population-Based Retrospective Cohort Study

BACKGROUND

People with schizophrenia spectrum disorders are at elevated risk of HIV, and people with both HIV and schizophrenia are at elevated risk of death compared with individuals with either diagnosis alone. Limited research has assessed the HIV care cascade, and in particular retention in care, among people with HIV (PWH) and schizophrenia in the United States.

METHODS

This population-based retrospective cohort study used Medicaid claims data to compare retention in HIV care between PWH with schizophrenia (n = 38,217) and matched controls without schizophrenia (n = 29,455) from 2001 to 2012. The primary outcome of annual retention in HIV care was at least 2 tests for CD4 + T-cell count or HIV viral load at least 90 days apart per year. Unadjusted and covariate-adjusted differences in period prevalence of retention among cases and controls were estimated.

FINDINGS

Annual retention in HIV care was 29.9% (95% CI: 29.4 to 30.4%) among people with schizophrenia and 38.5% (95% CI: 37.9 to 39.1%) among controls, representing 8.5% (95% CI: 9.3 to 7.7) lower retention in unadjusted and 9.0% (95% CI: 9.9 to 8.2) lower retention in adjusted estimates for people with HIV and schizophrenia. This disparity varied across states. Over time, retention increased and the disparity between people with and without schizophrenia diminished.

INTERPRETATION

PWH in the United States insured through Medicaid and diagnosed with schizophrenia experience lower retention in HIV care than controls. Suboptimal retention likely drives disparities in HIV-related morbidity and mortality for PWH with schizophrenia, and targeted individual and structural interventions are merited to improve the health of this population.

" … They cannot help you because you're at McDonald's and you're asking for pizza". A qualitative exploration of the acceptability and appropriateness of integrating of pharmacotherapy for mental health treatment in HIV care among patients living with HIV and co-morbid mental health and substance use disorders

Mental health disorders contribute to a lack of HIV care retention and adherence. Pharmacotherapy for mental health treatment may increase retention and adherence. However, there is often a lack of pharmacotherapy services for mental health treatment available in HIV care. The current study explores the extent to which people living with HIV find the integration of pharmacotherapy for mental health treatment into HIV care acceptable and appropriate. We conducted in-depth interviews with ten patients living with HIV and comorbid mental health or substance use challenges. We used rapid qualitative analysis to analyze the transcript data. Patients cited several barriers to mental health treatment, including having to coordinate and establish rapport with other providers. Participants' perspectives about whether HIV care providers should provide pharmacotherapy for mental health treatment varied. However, most respondents agreed that it would be beneficial for HIV care providers to maintain existing regimens or address lapses in mental health care. Patients also cited benefits to integration, including the ability to receive care from a trusted provider and increased access. These findings add to previous literature and demonstrate the nuanced nature of the acceptability of receiving pharmacotherapy for mental health treatment from an HIV care provider.

Mental health service utilization among patients followed up in tertiary HIV/AIDS clinics in Turkey: A need for integrated care

OBJECTIVES

Mental health (MH) care for people living with HIV (PLWH) emerges as an important unmet need, yet there are no integrated HIV-MH clinics in Turkey. Our aim is to determine MH service use and its associated factors in PLWH followed up in the HIV/AIDS outpatient clinics in Istanbul/Turkey.

METHODS

A cross-sectional study was conducted at the HIV/AIDS outpatient clinics of the Infectious Diseases (ID) departments in hospitals affiliated with the ACTHIV-IST Study Group. Structured interviews were performed using questionnaires that covered psychiatric state, medical history, and help-seeking behavior.

RESULTS

Out of 172 outpatients, 121 (70.3%) reported MH complaints after infection, and 65.6% felt a need to see MH professionals. Among those, 59% shared their MH distress with the ID team. However, only 20.7% applied to an MH service, and 16.5% received psychiatric treatment. Previous MH diagnoses (AOR = 4.11; 95%CI = 1.26-13.39), sharing the disease with the ID team (AOR = 4.18; 95%CI = 1.24-14.11), and being hospitalized due to HIV (AOR = 6.54; 95%CI = 1.21-35.39) emerged as the predictors of MH service use among those who would like to see an MH professional in logistic regression.

CONCLUSIONS

Closer contact with the healthcare system may increase the chances of PLWH receiving MH care. Thus, integrating MH services in HIV/AIDS care would help reach more PLWH who are distressed.

Identifying barriers and facilitators to psychosocial care for people living with HIV in Ireland: a mixed methods study

BACKGROUND

The effectiveness of antiretroviral therapy means that human immunodeficiency virus (HIV) can now be defined as a manageable chronic illness. It is the facilitation of psychosocial care that has increasingly become a priority, as people living with HIV (PLWH) are disproportionately impacted by psychosocial stressors compared to the general population. The aim of this study was to identify barriers and facilitators to psychosocial care for PLWH in Ireland.

METHODS

A mixed methods study design was used, employing a national survey of PLWH (n = 54) via Qualtrics and semi-structured interviews with healthcare professionals that provide clinical support to PLWH across Ireland (n = 11). Content analysis was used to analyse the interviews.

RESULTS

More than half (59.3%) of survey respondents agreed that living with HIV currently impacts their mental health, with nearly two thirds (64.8%) agreeing that they have experienced stigma as a result of living with HIV. Less than half (40.7%) were comfortable disclosing their status to family, and less than a third (27.8%) to friends. Stigma was identified by healthcare professionals as a barrier to psychosocial care, along with a number of system-level barriers, provider-level or practical barriers, and individual barriers. The value of multidisciplinary care teams and reliance on community support was emphasised, and potential for further integration of support services was highlighted.

CONCLUSION

Community-based organisations contribute significantly to the facilitation of psychosocial support for PLWH in Ireland, and greater integration of community services could promote a more holistic, patient-centred approach to meeting the diverse needs of this growing cohort. PLWH benefit from multidisciplinary care teams, and the facilitation of safe and effective peer support should be encouraged to afford opportunities to disclose and receive social support. HIV-related stigma remains a barrier to psychosocial care, highlighting the need for stigma reduction interventions.

Scoping review protocol of interventions for the mental health of women with and without HIV in Sub-Saharan Africa

INTRODUCTION

Mental health issues among women in Sub-Saharan Africa (SSA), especially those living with HIV, pose a major public health challenge. Despite the established connections between HIV status and mental health outcomes, there is a noticeable absence of targeted interventions for this group within the literature. Many studies tend to focus on broad mental health concerns without addressing the specific needs of women with HIV, or they neglect to incorporate mental health elements into current HIV-related programmes. This scoping review aims to gather and analyse the existing research on interventions designed to improve the mental health of women in SSA, both with and without HIV. It will identify barriers preventing this population from accessing mental healthcare, highlight important gaps in the current literature and suggest directions for future research.

METHODS AND ANALYSIS

To conduct this scoping review, the researcher will adhere to the methodological framework proposed by Arksey and O'Malley. The literature search will span several databases, including PubMed, MEDLINE, Web of Science and PsychInfo, to ensure a comprehensive collection of relevant studies. The selection process will involve two stages: two independent reviewers will initially screen titles for eligibility and a full-text review of the selected articles. A specially designed tool will be used for data extraction, focusing on minimising bias and accurately capturing study details. The final selection of studies will be analysed using a standardised tool to comprehensively assess all bibliographic information and study characteristics. The planned study dates for the review will be January to March 2025.

ETHICS AND DISSEMINATION

No ethical approval is required as the review will draw on publicly available publications and materials. The study's conclusions will be subject to peer review and published in a scientific journal, with the abstract shared at local and international conferences. Key findings will be disseminated to health ministries, community-based organisations focused on women's mental health and HIV, and policymakers to inform policy decisions regarding mental health interventions for women in SSA.

Integration of healthcare services for HIV and non-communicable diseases in sub-Saharan Africa: protocol for a scoping review of randomised controlled trials

INTRODUCTION

Stand-alone HIV clinics in sub-Saharan Africa (SSA) have effectively expanded antiretroviral therapy since the 2000s, transforming HIV from a deadly infection into a chronic condition. However, over the past decade, there has been a significant rise in the prevalence of non-communicable diseases (NCDs) globally and in SSA. People living with HIV are at higher risk for some NCDs, including hypertension, diabetes and different cancers. The region's current healthcare infrastructure is not equipped to address this growing burden. Integrating health services for HIV and NCDs (ie, combining services for HIV with services for hypertension, diabetes, depression and mental health, substance use disorder or cancer) could be one strategy for responding to these challenges. In this scoping review, we aim to identify randomised controlled trials on HIV-NCD integration, assess implemented integration models and measured outcomes and highlight evidence gaps.

METHODS AND ANALYSIS

This scoping review will follow the Arksey and O'Malley (2005) methodological framework. Reporting will be guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) checklist. We will conduct a systematic search of the databases OVID Medline, Embase, Web of Science, Global, Africa Index Medicus, including terms related to HIV, NCDs and healthcare integration. Included trials must have been conducted within SSA and have been published in English or French after 1 January 2010. We will not select based on sample size or number of clusters. Both the title and abstract screening and full-text screening will be done in Covidence by at least two reviewers working independently. Data extraction will focus on key variables, including study design, geographical location, integration intervention, measured outcomes and reported findings.

ETHICS AND DISSEMINATION

This scoping review aims to generate new insights from publicly available research. Therefore, ethical approval is not required. Study findings will be shared through discussion with policymakers, implementation science researchers and healthcare providers. The results of this study are intended to be published in a peer-reviewed journal.

TRIAL REGISTRATION

This protocol has been registered with Center for Open Science OSF Registry (DOI: 10.17605/OSF.IO/RGQSN). The search was conducted on 25 March 2024 and updated on 21 October 2024. The review is expected to be completed by March 2025.

Strengthening person-centered care through quality improvement: a mixed-methods study examining implementation of the Person-Centered Care Assessment Tool in Zambian health facilities

INTRODUCTION

Person-centered care (PCC) is considered a fundamental approach to address clients' needs. There is a dearth of data on specific actions that HIV treatment providers identify as priorities to strengthen PCC.

OBJECTIVE

This study team developed the Person-Centered Care Assessment Tool (PCC-AT), which measures PCC service delivery within HIV treatment settings. The PCC-AT, including subsequent group action planning, was implemented across 29 facilities in Zambia among 173 HIV treatment providers. Mixed-methods study objectives included: (1) identify types of PCC-strengthening activities prioritized based upon low and high PCC-AT scores; (2) identify common themes in PCC implementation challenges and action plan activities by low and high PCC-AT score; and (3) determine differences in priority actions by facility ART clinic volume or geographic type.

METHODS

The study team conducted thematic analysis of action plan data and cross-tabulation queries to observe patterns across themes, PCC-AT scores, and key study variables.

RESULTS

The qualitative analysis identified 39 themes across 29 action plans. A higher proportion of rural compared to urban facilities identified actions related to stigma and clients' rights training; accessibility of educational materials and gender-based violence training. A higher proportion of urban and peri-urban compared to rural facilities identified actions related to community-led monitoring.

DISCUSSION

Findings provide a basis to understand common PCC weaknesses and activities providers perceive as opportunities to strengthen experiences in care.

CONCLUSION

To effectively support clients across the care continuum, systematic assessment of PCC services, action planning, continuous quality improvement interventions and re-measurements may be an important approach.

A hybrid type II effectiveness-implementation trial of a positive emotion regulation intervention among people living with HIV engaged in Ryan White Medical Case Management: protocol and design for the ORCHID study

BACKGROUND

The Ryan White Medical Case Management System, which serves more than half of people living with HIV (PLWH) in the USA, is an opportune setting for identifying and addressing depression among PLWH. A growing body of research suggests that interventions that promote positive emotion may lessen symptoms of depression and improve physical and psychological well-being among people experiencing a variety of health-related stress, including living with HIV. Research on how best to integrate standardized mental health screening and referral to evidence-based interventions in Ryan White Medical Case Management settings has the potential to improve the health and wellbeing of PLWH.

METHODS

This mixed-methods study will enroll up to N = 300 Ryan White clients who screen positive for depressive symptoms in ORCHID (Optimizing Resilience and Coping with HIV through Internet Delivery), a web-based, self-guided positive emotion regulation intervention. The study will be conducted in 16 Ryan White Medical Case Management clinics in Chicago, IL. Following pre-implementation surveys and interviews with Medical Case Managers (MCMs) and Supervisors to develop an implementation facilitation strategy, we will conduct a hybrid type 2 implementation-effectiveness stepped wedge cluster randomized trial to iteratively improve the screening and referral process via interviews with MCMs in each wedge. We will test the effectiveness of ORCHID on depression and HIV care outcomes for PLWH enrolled in the program. RE-AIM is the implementation outcomes framework and the Consolidated Framework for Implementation Research is the implementation determinants framework.

DISCUSSION

Study findings have the potential to improve mental health and substance use screening of Ryan White clients, decrease depression and improve HIV care outcomes, and inform the implementation of other evidence-based interventions in the Ryan White Medical Case Management System.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05123144. Trial registered 6/24/2021.

Progress Toward Achieving National HIV/AIDS Strategy Goals for Quality of Life Among Persons Aged ≥50 Years with Diagnosed HIV - Medical Monitoring Project, United States, 2017-2023

Ensuring good quality of life (QoL) among persons with diagnosed HIV (PWH) is a priority of the National HIV/AIDS Strategy (NHAS), which established 2025 goals for improving QoL. Goals are monitored through five indicators: self-rated health, unmet needs for mental health services, unemployment, hunger or food insecurity, and unstable housing or homelessness. Among the growing population of PWH aged ≥50 years, progress toward these goals has not been assessed. Data collected during the 2017-2022 cycles of the Medical Monitoring Project, an annual complex sample survey of U.S. adults with diagnosed HIV, assessed progress toward NHAS 2025 QoL goals among PWH aged ≥50 years, overall and by age group. The recent estimated annual percentage change from baseline (2017 or 2018) to 2022 was calculated for each indicator. Among PWH aged ≥50 years, the 2025 goal of 95% PWH with good or better self-rated health is 46.2% higher than the 2022 estimate. The 2025 goals of a 50% reduction in the other indicators range from 26.3% to 56.3% lower than the 2022 estimates. Decreasing hunger or food insecurity by 50% among PWH aged ≥65 was the only goal met by 2022. If recent trends continue, other NHAS QoL 2025 goals are unlikely to be met. Multisectoral strategies to improve access to housing, employment, food, and mental health will be needed to meet NHAS 2025 goals for QoL among older PWH.

Person-centred care for older adults living with HIV in sub-Saharan Africa

More than a fifth of people living with HIV in the US President's Emergency Plan for AIDS Relief-supported programmes are older individuals, defined as aged 50 years and older, yet optimal person-centred models of care for older adults with HIV in sub-Saharan Africa, including screening and treatment for geriatric syndromes and common comorbidities associated with ageing, remain undefined. This Position Paper explores the disproportionate burden of comorbidities and geriatric syndromes faced by older adults with HIV, with a special focus on women. We seek to motivate global interest in improving quality of life for older people with HIV by presenting available research and identifying research gaps for common geriatric syndromes, including frailty and cognitive decline, and multimorbidity among older people with HIV in sub-Saharan Africa. We share two successful models of holistic care for older people with HIV that are ongoing in Zimbabwe and Kenya. Lastly, we provide policy, research, and implementation considerations to best serve this growing population.

Prevalence of Diagnosed and Undiagnosed Depression Among US Adults with Human Immunodeficiency Virus: Data from the Medical Monitoring Project

People with human immunodeficiency virus (PWH) are disproportionately affected by depression, but the recent national estimates for US PWH encompassing both current symptoms and clinical diagnoses to assess missed diagnoses and lack of symptom remission are lacking. We used data from CDC's Medical Monitoring Project (MMP) to report nationally representative estimates of diagnosed and undiagnosed depression among US adult PWH. During June 2021 to May 2022, MMP collected interview data on symptoms consistent with major or other depression and depression diagnoses from medical records of 3928 PWH. We report weighted percentages and prevalence ratios (PRs) to quantify differences between groups on key social and health factors. Overall, 34% of PWH experienced any depression (diagnosis or Patient Health Questionnaire-8); of these, 26% had symptoms but no diagnosis (undiagnosed depression), 19% had both diagnosis and symptoms, and 55% had a diagnosis without symptoms. Among those with depression, persons with a disability (PR: 1.52) and food insecurity (PR: 1.67) were more likely to be undiagnosed. Unemployed persons (PR: 1.62), those experiencing a disability (PR: 2.78), food insecurity (PR: 1.46), or discrimination in human immunodeficiency virus (HIV) care (PR: 1.71) were more likely to have diagnosed depression with symptoms. Those with symptoms (undiagnosed or diagnosed) were less likely to be antiretroviral therapy (ART) dose adherent (PR: 0.88; PR: 0.73) or have sustained viral suppression (PR: 0.62; PR: 0.91) and were more likely to have unmet needs for mental health services (PR: 2.38, PR: 2.03). One-third of PWH experienced depression, of whom nearly half were undiagnosed or still experiencing clinically relevant symptoms. Expanding screening and effective treatment for depression could improve quality of life and HIV outcomes.

Exploring Effective Approaches: Integrating Mental Health Services into HIV Clinics in Northern Uganda

Background

Integrating mental health services into HIV clinics is recognized as a promising strategy. However, the literature reveals gaps, particularly in the unique context of Northern Uganda, where factors such as historical conflict, stigma, and limited resources pose potential barriers.

Material and Methods

This qualitative study, conducted between October and November 2023, employed a phenomenological design. The study involved primary healthcare facilities across diverse urban and rural settings, focusing on healthcare providers, village health teams, and service users. A purposive sampling approach ensured diverse demographics and perspectives. In-depth interviews and focus group discussions were conducted, with healthcare providers and service users participating individually, and village health teams engaged in group discussions. Thematic analysis was employed during data analysis.

Results

Findings revealed a predominance of females among healthcare providers (18 of 30) and service users (16 of 25), as well as in VHTs. Average ages were 33.4 (healthcare providers), 38.5 (service users), and 35.1 (VHTs). Most healthcare providers (15) held diplomas, while 12 service users and 4 VHTs had certificates. The majority of healthcare providers (n=20) and 4 VHTs had 6-10 years of experience. Thematic analysis highlighted three key themes: benefits of integrated mental health services, implementation challenges, and the role of community engagement and cultural sensitivity.

Conclusion

This study contributes valuable insights into the integration of mental health services into HIV clinics in Northern Uganda. The perceived benefits, challenges, and importance of cultural sensitivity and community engagement should guide future interventions, fostering a holistic approach that enhances the overall well-being of individuals living with HIV/AIDS in the region. Policymakers can use this information to advocate for resource allocation, training programs, and policy changes that support the integration of mental health services into HIV clinics in a way that addresses the identified challenges.

Mental health burden among females living with HIV and AIDS in sub-Saharan Africa: A systematic review

Mental health problems, particularly depression and anxiety, are common in women and young girls living with HIV/ AIDS particularly in low- and middle-income (LMICs) countries where women's vulnerability to psychiatric symptoms is heightened due to the prevalent intersectional stressors such as stigma and intimate partner violence. However, no synthesized evidence exists on the mental health burden of females living with HIV/AIDS (FLWHA) in Africa. This systematic review aimed to synthesize the current evidence on the mental health burden among FLWHA in sub-Saharan Africa. A systematic literature review of articles published from 2013-2023 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA). Five electronic databases; PubMed, MEDLINE with full text, Scopus, Academic Search Complete, and Health Source: Nursing Academic Edition were searched for articles published in English. Nineteen articles (15 quantitative, 3 qualitative, and 1 case study) from over 7 African countries met the inclusion criteria. The majority of the studies' quality was determined to be moderate. The prevalence of depression ranged from 5.9 to 61% and anxiety from 28.9 to 61%. Mental health burden was a logical outcome of HIV diagnosis. Predictors of mental health outcomes in the context of HIV/AIDS were identified as intimate partner violence (IPV), stigma, childhood traumas, sexual abuse, poverty, unemployment, and social isolation. Social support and resilience were identified as protective factors against mental illness in FLWHA. Mental illness had a deleterious effect on viral suppression rates among FLWHA, resulting in delayed initiation of antiretroviral therapy treatment and increased mortality but had no impact on immune reconstitution in the face of ART adherence. Given the high prevalence rates of depression and anxiety and their relationship with HIV progression, it is crucial that mental health care services are integrated into routine HIV care.

Development and internal validation of a risk prediction model for HIV disease severity among people living with HIV and mental illness or substance use disorder

PURPOSE

Mental illness (MI) and substance use disorders (SUD) are highly prevalent among people living with HIV (PLWH), and have been linked to poor HIV clinical outcomes. Innovative tools for early risk identification can facilitate timely interventions for PLWH and MI/SUD to improve their health outcomes, however, this is currently lacking in Texas, a state with the 4th largest population of PLWH in the United States. To address this gap, we developed a predictive model to estimate the risk of suboptimal HIV clinical outcomes among PLWH and MI/SUD in Texas.

METHODS

The Texas Medical Monitoring Project data obtained from June 2015-May 2020 were used to develop and internally validate the predictive model. Univariate descriptive and bivariate inferential statistics were performed to describe the characteristics of the study population and unadjusted associations with HIV clinical outcomes. Multivariable logistic regression was used to develop the prediction model. Internal validation was performed using the bootstrap method.

RESULTS

A total of 518 respondents aged 18 years and above, representing 27,255 adults living with HIV and mental illness or substance use disorders in Texas were included. Most participants were male (77.0%), less than 50 years of age (60.0%), and had mild diagnosed mental illness and substance use disorder (54.8%). The risk predictive model contained eight predictors, which together yielded an area under the receiver operating characteristic (ROC) curve of 0.727. Non-retention in care appeared to be the strongest risk predictor for having suboptimal HIV clinical outcome (adjusted odds ratio (aOR) = 3.27; 95% confidence interval (CI) = 1.45, 7.42).

CONCLUSIONS

The predictive model had good discrimination between persons at risk of poor HIV clinical outcomes and those not at risk.

Barriers and facilitators to integrating depression care in tuberculosis services in South Asia: a multi-country qualitative study

BACKGROUND

Depression is common among people with tuberculosis (TB). The condition is typically unrecognised or untreated despite available and effective treatments in most low- and middle-income countries. TB services in these countries are relatively well established, offering a potential opportunity to deliver integrated depression screening and care. However, there is limited evidence on how such integration could be achieved. This study aimed to understand the barriers and facilitators to integrate depression care in TB services.

METHODS

We conducted nine workshops with 76 study participants, including people with TB, their carers, and health service providers in Bangladesh, India, and Pakistan, seeking views on integrating depression care into TB clinics. We used a deductive thematic approach to analyse the translated transcripts of audio recordings, contemporaneous notes made during workshops for Bangladesh and India and workshop reports for Pakistan. Using the SURE (Supporting the Use of Research Evidence) thematic framework, we extracted and categorised barriers and facilitators into various domains.

RESULTS

Reported barriers to integrating depression care in TB services included lack of knowledge about depression amongst patients and the staff, financial burden, and associated stigma for people with TB and their carers. Government buy-in and understanding of how to identify and screen for depression screening were potential facilitators reported. Additionally, breaking through mental health stigma and providing the additional resources required to deliver this service (human resources and consultation time) were essential for integrating depression and TB care.

CONCLUSIONS

Depression is a common condition found among people with TB, requiring early identification among people with TB. Integrating depression care into Tb services by health workers requires the availability of political support and the provision of resources.