HIV and mental Health

Although people with serious mental illness tend to be less sexually active, they have a higher risk of sexual behaviour

Kampala, Uganda | PATRICIA AKANKWATSA | People who have or are at a risk of HIV and who are vulnerable to mental health conditions often face other significant individual, structural, social, and biological challenges to accessing and adhering to HIV prevention and treatment modalities.

These challenges could be due to sociodemographics, neighbourhood and local environmental factors, social structures, individual biology, and intersecting societal stigmas.

Structural factors include poverty, low education, unstable housing, and food insecurity while neighbourhood and environmental factors include violence and lack of safety, safe and steady water supply, wars, and natural disasters.

Biological factors include related communicable diseases such as tuberculosis and hepatitis and non-communicable diseases such as diabetes, heart, and bone disease and chronic immune activation.

They all contribute to increased vulnerability to HIV infection, cause psychological trauma, disrupt the delivery of medical supplies, present barriers to healthcare access, and contribute to poorer physical and mental health outcomes.

Intersecting social stigmas and criminalisation including sex work, drug use, and same-gender sex, present additional challenges to key populations that are highly affected by HIV. These include transgender women, sex workers, people who use drugs (including PWID), and racial and ethnic minorities.

These groups experience perceived and internalised stigma as well as enacted stigma and discrimination that negatively affect mental health. This relationship is further compounded by the unfortunate stigma of mental illness in society and among patients and providers.

A new publication titled ‘Integration of mental health and HIV interventions: Key considerations by UNAIDS and the World Health Organisation (WHO)’ emphasizes the importance of integrating HIV and mental health services and other interventions; including linkages to social protection services, for people living with HIV and other vulnerable populations.

According to the publication, effective methods of prevention, screening and diagnosis of, and treatments for, common mental health conditions, including depression and anxiety, exist and can be implemented in low- and middle-income countries, services for mental health, neurological and substance use conditions are often not integrated into packages of essential services and care, including for HIV.

“We know that integration of screening, diagnosis, treatment and care for mental health conditions and psychosocial support with HIV services does not need to be expensive,” said Eamonn Murphy, UNAIDS Deputy Executive Director during a webinar launch of the publication on April 29th.

“The integrated approaches that are people-centred and local context-specific ensure better HIV and overall health outcomes, well-being and quality of life,”

The publication is primarily intended for national and local policy-makers, global, regional, country and local programme implementers, organizations working in and providers of health, HIV, mental health and other relevant services, civil society and community-based and community-led organizations and advocates.

“Our publication successfully brings together tools, best practices, case studies and guidelines that can help countries and facilitate the integration of interventions and services to address the interlinked public health challenges of mental health and HIV, all while improving access to care for persons who are the most vulnerable, such as adolescents and key populations,” said Meg Doherty, Director, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO.

Integration of mental health and psychosocial support with HIV services and interventions, including those led by communities, is one of the key priority actions included in the Global AIDS Strategy 2021–2026: End Inequalities, End AIDS and the 2021 United Nations Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030.s

“With this joint UNAIDS/WHO publication, we hope we can collectively support countries, service providers and other practitioners, policy-makers, programme implementers and communities in their efforts to address HIV, mental health, neurological and substance use conditions for affected individuals in an integrated and impactful way,” said Devora Kestel, Director, Mental Health and Substance Use, WHO.

Both documents call for addressing the interlinked issues of HIV and mental health through integrated services by investing in robust, resilient, equitable and publicly-funded systems for health and social protection, reversing health and social inequalities and ending stigma and discrimination.

The new publication stresses that the AIDS epidemic cannot end without addressing the mental health of people living with, at risk of or affected by HIV, ensuring equitable access to HIV services for people with mental health issues and conditions and achieving universal health coverage.

Uganda case

According to the Uganda Population-based HIV Impact Assessment (UPHIA) 2020 survey sample of adults aged 15 years and older, HIV prevalence was 5.8 % (7.2 % among women and 4.3% among men) corresponding to approximately 1.3 million adults living with HIV in Uganda.

Although this is a slight decrease from 6% in 2016-2017, mental health conditions continue to increase the risk of HIV infection, and people living with HIV have an increased risk of mental health conditions, which are associated with lower retention in HIV care, increased risk behaviours and lower engagement with HIV prevention.

Eugene Kinyanda a senior scientist and head of the mental health research project at the MRC/UVRI Uganda Research Unit on AIDS (MRC/UVRI) says that mental health disorders play a critical role in HIV acquisition across populations, increasing the risk of HIV acquisition.

“Mental health problems can increase the risk of HIV acquisition through both direct and indirect pathways,” he says.

“Although people with serious mental illness tend to be less sexually active compared with the general population, sexually active adolescents and adults with serious mental illness, evidence higher-risk sexual behaviour, including inconsistent condom use, having multiple sexual partners, trading sex, and drinking alcohol before sex,” he adds.

With an estimated 1.4 million people living with HIV/AIDS in Uganda, studies have reported an exceptionally high prevalence of depressive symptoms among People Living with HIV (PLWH) posing a major challenge in HIV care despite the success of antiretroviral therapy’s scale-up (ART) and consequently increasing mortality.

In Uganda, a recent meta-analysis found a pooled depression prevalence of 31% among PLWH, nearly ten times higher than the prevalence estimates in the general population.

Depression in people living with HIV not only affects the quality of life but has been associated with several other negative behavioural and clinical outcomes such as more rapid HIV disease progression including mortality, poor adherence to HIV treatment, risky sexual behaviour and increased utilization of health facilities.

In response to this absence of mental health care in HIV programs, the Uganda National HIV and AIDS Strategic Plan (2015–2020) called for the integration of mental health and other chronic conditions in HIV care to further improve the quality of care and treatment.

To operationalize this policy recommendation, the Ministry of Health released guidelines for the treatment of HIV calling for the assessment and management of depression as an integral part of HIV care programmes.

Although the need for integrating HIV and mental health services is indisputable, the challenges are evident in implementing a service integration model that is cost-effective, and of high quality and impact.

Currently, in Uganda, there is no mental health care in HIV care services provided at public health care facilities in the country.

Challenges to such provision include; low demand for formal mental health services (most patients with mental health problems first seek care from traditional healers and/or faith healers, and a severe shortage of mental health professionals.

Uganda has only 47 psychiatrists, the majority of whom work in the capital city of Kampala.

The reluctance of primary care providers to engage in mental health care due to lack of training in mental health, appreciation of the value of mental health care and the time and resources due to competing demands, a severe shortage of primary care workers, and poor funding of the mental health sector. Of the 9.8% spent on healthcare, only 1% goes to mental healthcare.

According to the publication, many factors contribute to the high comorbidity of HIV and mental health conditions.

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