iconstar paper   HIV Articles  
Back grey arrow rt.gif
 
 
Mental health and HIV/AIDS the need for an integrated response. Depression Doubles Mortality in WIHS Women
 
 
  Download the PDF
 
• "In the Women's Interagency HIV Study prospective cohort (N = 848), chronic depressive symptoms were associated with over three times the hazard of mortality, among women on cART, and over seven times the hazard of mortality, among women not on cART, compared with women on cART with no depression
 
• Depression has been shown to increase the risk of mortality among PLWH.
 
• And among 765 HIV+ women at four US sites followed for up to 7 years, women with chronic depressive symptoms were twice as likely to die as women with limited or no depressive symptoms, even after adjusting for predictors of mortality (i.e., CD4+ cell count, cART duration, age)
 
• Biological factors, including comorbid communicable diseases (e.g. tuberculosis, hepatitis) and noncommunicable diseases (e.g. diabetes, heart, and bone disease), as well as chronic immune activation, contribute to poorer physical and mental health outcomes"
 
• In a US multisite study with over 2800 PLWH, 36% had major depression and 15.8% had generalized anxiety disorder [36], compared with only 6.7 and 2.1%, respectively, in the general population
 
• Prevalence of substance use disorders also tend to be higher among PLWH than in the general poulation ranging from 21 to 71% [44,54], as do rates of neurocognitive impairment - about 50% of PLWH, even those who are virally suppressed
 
Remien, Robert H.a; Stirratt, Michael J.b; Nguyen, Nadiaa; Robbins, Reuben N.a; Pala, Andrea N.a; Mellins, Claude A.a AIDS: July 15, 2019
 
• Biological factors, including comorbid communicable diseases (e.g. tuberculosis, hepatitis) and noncommunicable diseases (e.g. diabetes, heart, and bone disease), as well as chronic immune activation, contribute to poorer physical and mental health outcomes [61,62]. Intersecting social stigmas, and criminalization in some contexts (e.g. sex work, drug use, and same-gender sex) present additional challenges to key populations that are highly affected by HIV, including MSM, transgender women, sex-workers, people who use drugs (including PWID), and racial and ethnic minorities. These groups experience perceived and internalized stigma as well as enacted stigma (e.g. discrimination) that negatively affect mental health, and this relationship is further compounded by the unfortunate stigma of mental illness in society and among patients and providers [63-65].
 
• And among 765 HIV+ women at four US sites followed for up to 7 years, women with chronic depressive symptoms were twice as likely to die as women with limited or no depressive symptoms, even after adjusting for predictors of mortality (i.e., CD4+ cell count, cART duration, age)
 
• Mental disorders can present a substantial barrier to adequate engagement and retention in HIV primary care. Research has established links between the presence of psychiatric illness and poor rates of HIV care linkage and retention.
 
• Lack of HIV diagnosis jeopardizes the health of PLWH by impeding access to the significant health benefits that cART confers. Lack of HIV diagnosis presents a further public health challenge because a substantive proportion of new HIV infections are attributable to persons who are not aware of their HIV status
 
• There is evidence suggesting a bi-directional relationship between depression and the immune system [79-81]. Depression is known to negatively affect the immune system (e.g. CD4+ cell decline) although the underlying mechanisms remain poorly understood. Chronic immune activation and hypothalamic-pituitary-adrenal axis dysregulation [82,83], which HIV infection can exacerbate [84-86], are established factors contributing to developing depression and likely contribute to high rates of depression among PLWH [62]. HIV crosses the blood brain barrier causing immune activation in the brain and the central nervous system [87]. Inflammatory proteins (e.g. C-reactive protein, cytokines) lead to oxidative stress and neuronal injury [88], specifically, the chronic inflammatory response to HIV infection leads to elevated cytokine levels, including IL-6 and TNF-α, which can trigger a chain reaction involving Tryptophan depletion through the activation of Indoleamine 2,3-dioxygenase enzyme
 
• Community advocates have built on this science by advancing a messaging campaign regarding 'U = U' (undetectable = untransmittable), which states that PLWH with sustained HIV viral suppression cannot transmit HIV through sex [133,134]. The campaign holds that the optimistic messaging of U = U will build hope in the community and contribute to a lessening of HIV-related stigma, which in turn can reduce psychological distress among PLWH and their sex partners. Community advocates and anecdotal reports indicate that the U = U message helps many PLWH feel unburdened by the shame and stigma that accompanies HIV infection [133]. There is a need for systematic research on patient understanding of U = U and its potential benefits for mental health and well being among PLWH.
 
Conclusion
 
Our review has identified the following understandings about the intersection of mental health and HIV/AIDS:
 
1 Mental health problems (ranging from distress to SMI) are elevated among people at-risk for HIV and those living with HIV. This risk is true across populations most affected by the epidemic in different regions of the world.
2 Mental health problems contribute to HIV acquisition and poor outcomes along the HIV treatment continuum.
3 HIV and the resulting chronic immune activation increase the risk to develop mental health problems.
4 We have the necessary assessment (screening) tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment, especially mental health treatment integrated into HIV care, with appropriate resources to address the current screening and treatment gap. 5 Promising advances have been made integrating mental healthcare into HIV primary care (via task-shifting, stepped-care interventions, and other strategies).
6 Some community and public health driven campaigns regarding HIV treatment and prevention may help reduce stigma and psychological distress.
 
Despite the significant challenges that mental health presents to HIV prevention and treatment, there are many important and unmet opportunities to integrate mental healthcare with HIV care. Initiatives like PEPFAR have helped countries around the world dramatically expand HIV care, and the concomitant strengthening of their healthcare systems has offered substantial benefits to wider healthcare delivery. Further integration of mental health screening and care into this infrastructure would not only strengthen HIV prevention and care outcomes, but it would additionally improve global access to mental healthcare. Seizing these opportunities will be crucial if we are to further 'bend the curve' of the HIV epidemic and eventually find an end to AIDS. On a very fundamental and basic level, there can be no health, without mental health.
 
"Rates of mental health problems are higher among both people vulnerable to acquiring HIV and PLWH, compared with the general population.....Mental health impairments increase risk for negative health outcomes among PLWH ...Depression has been shown to increase the risk of mortality among PLWH: In the Women's Interagency HIV Study prospective cohort (N = 848), chronic depressive symptoms were associated with over three times the hazard of mortality, among women on cART, and over seven times the hazard of mortality, among women not on cART, compared with women on cART with no depression ......Depression is known to negatively affect the immune system: Chronic immune activation and hypothalamic-pituitary-adrenal axis dysregulation [82,83], which HIV infection can exacerbate are established factors contributing to developing depression and likely contribute to high rates of depression among PLWH - HIV crosses the blood brain barrier causing immune activation in the brain and the central nervous system [87]. Inflammatory proteins (e.g. C-reactive protein, cytokines) lead to oxidative stress and neuronal injury [88], specifically, the chronic inflammatory response to HIV infection leads to elevated cytokine levels, including IL-6 and TNF-α, which can trigger a chain reaction involving Tryptophan depletion through the activation of Indoleamine 2,3-dioxygenase enzyme......Many studies have shown that PLWH experience higher rates of mental health disorders than the general population. This includes research conducted with diverse groups of PLWH such as youth with perinatal or behaviorally acquired HIV, adult MSM of color, racial and ethnic minority women, people who inject drugs (PWID), and older adults [36-42]. In a US multisite study with over 2800 PLWH, 36% had major depression and 15.8% had generalized anxiety disorder [36], compared with only 6.7 and 2.1%, respectively, in the general population...Biological factors, including comorbid communicable diseases (e.g. tuberculosis, hepatitis) and noncommunicable diseases (e.g. diabetes, heart, and bone disease), as well as chronic immune activation, contribute to poorer physical and mental health outcomes .......Tremendous advances have been made in HIV prevention and treatment......these gains will not be achieved without addressing the significant mental and substance use problems among people vulnerable to acquiring or living with HIV, which exacerbate the many social and economic barriers to accessing adequate and sustained healthcare .......In the iPrEx and iPrEx-OLE trials, which studied PrEP efficacy and open-label use among MSM and transgender women, participants with higher depression scores had lower levels detectable PrEP medication (emtricitabine and tenofovir disoproxil fumarate) and higher levels of condomless receptive anal intercourse [34,35]. Screening and treatment for mental health problems and disorders will be essential to preventing vulnerable populations from acquiring HIV......There is substantial evidence that impairment in mental health leads to negative health outcomes at each step in the HIV care continuum, starting with being diagnosed with HIV, all the way to achieving viral suppression. Lack of HIV diagnosis jeopardizes the health of PLWH by impeding access to the significant health benefits that cART confers.......there is an obvious need for universal mental health screening and the provision of mental health treatment integrated into ongoing HIV care...... technology-based approaches like telephone-delivered and computer-delivered interventions can help scale mental healthcare and support lay-counselor interventions with PLWH who are in need [129,130]. Internet-based mental health interventions, such as internet-based cognitive behavioral therapies [131] are growing in popularity globally to improve access in low resource contexts, as well as among youth and young adults who are at high risk for nonadherence or nonaccess of mental health resources.......Community advocates have built on this science by advancing a messaging campaign regarding 'U = U' (undetectable = untransmittable), which states that PLWH with sustained HIV viral suppression cannot transmit HIV through sex [133,134]. The campaign holds that the optimistic messaging of U = U will build hope in the community and contribute to a lessening of HIV-related stigma, which in turn can reduce psychological distress among PLWH and their sex partners. Community advocates and anecdotal reports indicate that the U = U message helps many PLWH feel unburdened by the shame and stigma that accompanies HIV infection [133]. There is a need for systematic research on patient understanding of U = U and its potential benefits for mental health and well being among PLWH.
 
Increased availability and use of effective HIV primary prevention tools could importantly benefit mental health, as well. The high efficacy of PrEP in nearly eliminating the risk of HIV acquisition among HIV-negative individuals adhering to PrEP has been shown to significantly reduce symptoms of anxiety and depression among young people vulnerable to acquiring HIV [135-137]. There is also emerging evidence that engagement in PrEP care can simultaneously promote greater engagement in screening and treatment for mental and behavioral health challenges, as well as screening and treatment for other health conditions, such as diabetes, hypertension, and tobacco use [138]. With this understanding, expanded PrEP care delivery and use could benefit both HIV prevention and mental health."
 
Tremendous biomedical advancements in HIV prevention and treatment have led to aspirational efforts to end the HIV epidemic. However, this goal will not be achieved without addressing the significant mental health and substance use problems among people living with HIV (PLWH) and people vulnerable to acquiring HIV. These problems exacerbate the many social and economic barriers to accessing adequate and sustained healthcare, and are among the most challenging barriers to achieving the end of the HIV epidemic. Rates of mental health problems are higher among both people vulnerable to acquiring HIV and PLWH, compared with the general population. Mental health impairments increase risk for HIV acquisition and for negative health outcomes among PLWH at each step in the HIV care continuum. We have the necessary screening tools and efficacious treatments to treat mental health problems among people living with and at risk for HIV. However, we need to prioritize mental health treatment with appropriate resources to address the current mental health screening and treatment gaps. Integration of mental health screening and care into all HIV testing and treatment settings would not only strengthen HIV prevention and care outcomes, but it would additionally improve global access to mental healthcare.

 
 
 
 
  iconpaperstack View Older Articles   Back to Top   www.natap.org