Patient Care

Engagement Along the HIV Care Continuum and the Potential Role of Mental Health and Substance Use Disorders

Fed Pract. 2015 February;32(suppl 2):10S-14S

References

1. Office of Public Health/Population Health. National HIV Registry Reports: 2013. Personal Communication October 1, 2014.

2. Veterans Health Administration. Where do I get the care I need? VA website. http://www.va.gov/health/findcare.asp. Accessed October 3, 2014.

3. Maier M, Chartier M. Department of Veterans Affairs: HIV program, policies, and infrastructure. HIV Specialist. 2014;6(2):19-25.

4. Center for Quality Management in Public Health. The State of Care for Veterans with HIV/AIDS: 2011 Summary Report. Washington, DC: U.S. Department of Veterans Affairs, 2012.

5. Cohen MS, Chen YQ, McCauley M, et al; HPTN 052 Study Team. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493-505.

6. HIV/AIDS Care Continuum. AIDS.gov Website. http://aids.gov/federal-resources/policies/care-continuum. Updated December 18, 2013. Accessed October 6, 2014.

7. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Key graphics from CDC analysis showing proportion of people engaged in each of the five main stages of HIV care. Centers for Disease Control and Prevention Website. http://www.cdc.gov/nchhstp/newsroom/2012/Continuum-of-Care-Graphics.html. Updated December 27, 2013. Accessed November 18, 2014.

8. Mangal JP, Rimland D, Marconi VC. The continuum of HIV care in a Veterans’ Affairs clinic. AIDS Res Hum Retroviruses. 2014;30(5):409-415.

9. Gardner EM, McLees MP, Steiner JF, Del Rio C, Burman WJ. The spectrum of engagement in HIV care and its relevance to test-and-treat strategies for prevention of HIV infection. Clin Infect Dis. 2011;52(6):793-800.

10. Hall HI, Frazier EL, Rhodes, P, et al. Differences in human immunodeficiency virus care and treatment among subpopulations in the United States. JAMA Intern Med. 2013;173(14):1337-1344.

11. Chartier M, Blais RK, Steinberg T, et al. A psychology postdoctoral fellowship program in integrated HIV and hepatitis C clinical care: Rationale, progress, and future directions. Training Educ Professional Psychol. doi: 10.1037/tep0000038.

12. Hinkin CH, Castellon SA, Atkinson JH, Goodkin K. Neuropsychiatric aspects of HIV infection among older adults. J Clin Epidemiol. 2001;54(suppl 1):S44-S52.

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15. Leserman J. HIV disease progression: Depression, stress, and possible mechanisms. Biol Psychiatry. 2003;54(3):295-306.

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18. Simoni JM, Amico KR, Smith L, Nelson K. Antiretroviral adherence interventions: Translating research findings to the real world clinic. Curr HIV/AIDS Rep. 2010;7(1):44-51.

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Although national VHA data on the HIV Care Continuum Initiative are not currently available, this study helps to illustrate the high quality of HIV care in the VHA relative to other national samples.

Mental Health and Substance Use

Although individual facilities within VHA may perform better across the care continuum compared with national samples, as a health care system, significant dropoffs remain at each stage, particularly in the transition from linkage to care to retention in care. The barriers to engagement in care at various steps along this continuum are not well understood, although mental health and substance use disorder (MH/SUD) comorbidities likely play an important role.

Mental health and substance use disorder comorbidities impact over half of veterans with HIV infection in VHA care. In 2012, 55% of veterans with HIV infection in care had ever been diagnosed with depression, 31% with anxiety, 16% with posttraumatic stress disorder (PTSD), and 62% with any mental illness (Table). ¹¹ Substance use is also quite prevalent in veterans with HIV infection, with 34% reporting a history of alcohol abuse, 28% a history of stimulant use, and 16% a history of cannabis use in 2012; nearly 50% reported tobacco use.

Compared with that of the general population, MH/SUDs are much higher among people living with HIV/acquired immune deficiency syndrome (AIDS) and higher still among veterans living with HIV/AIDS. ^11-13 Mental health conditions such as depression, anxiety and PTSD as well as substance use have been linked not only to increases in HIV risk behavior, but also to more rapid progression of HIV and increases in AIDSdefining illnesses and death. ^14-16 The high burden of MH/SUD among veterans with HIV is further complicated by the fact that this is an aging population. The risk of HIV-associated neurocognitive disorders (HAND) as well as non–HIV-related neurocognitive disorders increases with age. ^17,18 These risks may be higher for those with comorbid MH/SUD, and this interaction may increase patients’ vulnerability to HAND. ^12,19,20

The HIV care continuum is characterized by engagement at each step. Psychiatric and substance use problems represent potential engagementlimiting comorbidities. Several studies highlight the importance of addressing MH/SUDs that have adverse effects on adherence, linkage to and retention in care, and care utilization patterns. ^13,18,21-24 HIV-related stigma may also play a significant role in disengagement in care, adherence, patient satisfaction with care, and follow-up. ^25-28

Overall, integrated HIV care has been found to positively impact hospital utilization, quality of life and functioning, adherence, patient satisfaction, and process outcomes. ²⁹ Integrated HIV care is a specific intervention that could positively impact the HIV care continuum, particularly in managing depression and substance use. ^28,30,31 In the VHA, integrated HIV care is associated with increased access to mental health services and increased viral suppression compared with nonintegrated HIV clinics in VHA. ^32,33

A qualitative study of care integration found that in VHA HIV clinics that were integrated, patients reported less stigma and more positive relationships with their providers. ³⁴The VHA Office of Public Health, in collaboration with the Office of Academic Affiliations, has supported the expansion of a postdoctoral fellowship in clinical psychology with a specific focus on integrated HIV and hepatitis C clinical care in an effort to increase the availability of mental health providers specifically trained to address MH/SUDs in the HIV-infected population. This national fellowship program has been described in detail elsewhere. ¹¹