In this Issue:
- Behavioral Health Conditions Among People Living with HIV
- Ryan White HIV/AIDS Program and Integrated Care to Improve Behavioral Health Outcomes
- Screening for Behavioral Health Disorders: A Critical Component of Integrated Care
This edition of HRSA CAREAction examines how integrating behavioral health services into primary care can better support the emotional, psychological, and social well-being of people living with HIV (PLWH) to achieve optimal HIV health outcomes. Behavioral health conditions, such as mental disorders and substance use disorders (SUDs), can make it more challenging for PLWH to manage their daily lives, attend medical appointments, connect with support networks, engage in healthy behaviors, and adhere to treatment plans—all of which may lead to the progression of HIV. Because of the detrimental effects of behavioral health conditions on HIV health outcomes, traditional service delivery approaches often do not provide the level of comprehensive and integrated care that PLWH who have behavioral health disorders need.
Since its implementation 27 years ago, the Health Resources and Services Administration’s Ryan White HIV/AIDS Program has been addressing the comprehensive health care needs of PLWH, including behavioral health services. In 2014, almost 75 percent of Ryan White HIV/AIDS Program provider organizations provided mental health services, and 34 percent provided SUD services. Integrating behavioral health services into primary care is one of the most effective ways to care for people with multiple health care needs and improve both medical and behavioral health outcomes among PLWH. This newsletter features several Program recipients’ “stories from the field,” or best practices that demonstrate some of the many ways to integrate behavioral health services into HIV care.
Laura W. Cheever, M.D., Sc.M.
Associate Administrator for the HIV/AIDS Bureau, Health Resources and Services Administration
BEHAVIORAL HEALTH CONDITIONS AMONG PEOPLE LIVING WITH HIV
Although the ultimate goal of HIV care for people living with HIV (PLWH) is to achieve viral suppression, accessing HIV care and following treatment plans, including antiretroviral therapy, can be complicated by co-occurring behavioral health conditions. These conditions can include such mental disorders as depression and anxiety, trauma, and substance use disorders (SUDs), such as alcohol and illegal drug use. PLWH often have more than one behavioral health condition, which makes it even more difficult for them to follow HIV treatment plans and reach the goal of viral suppression. Having a behavioral health disorder also increases the likelihood of engaging in risky behaviors, such as unsafe sex and substance misuse, and often interferes with medication adherence and leads to worse health outcomes and quality of life. 1,2,3
Mental Disorders Among PLWH
Having a condition as serious as HIV is a source of stress for many PLWH and may result in the development of mental disorders, such as depression and anxiety, or complicate existing mental disorders. It has been estimated that as many as 50 percent of PLWH in care also have mental disorders. Approximately 36 percent of these have depression, and 16 percent have anxiety.4 A 2008 study stated that the rate of co-occurring mental disorders among PLWH was so high that “having a single mental health diagnosis was the exception rather than the rule.”5 Depression rates among PLWH receiving care are about three times higher than in the general population.6 Anxiety symptoms are common among people with depression and can develop or recur for many reasons, including a patient’s worries about HIV infection and treatment or issues unrelated to HIV. Depression, anxiety, and other mental disorders can have profound effects on the physical and mental well-being of a person living with HIV. Research shows that depression may lower immune function, increase the risk of heart disease and other comorbidities, and result in early death.7
Trauma Among PLWH
Many PLWH in need of behavioral health services have experienced or witnessed interpersonal and/or community-level trauma, such as physical and sexual abuse, verbal abuse or assault, neglect, bullying, and community-based violence. These experiences may lead to symptoms of posttraumatic stress disorder (PTSD), including depression and anxiety, and may worsen the overall health and function of PLWH.
Trauma can also result in social isolation, feelings of anger and distrust, and SUDs. PLWH who experience trauma have higher rates of mental health conditions than the general population. Approximately 42 percent of PLWH have experienced trauma and live with PTSD. Additionally, women experience PTSD at a much higher rate than men.8 One study found that approximately 30 percent of HIV-positive women experience PTSD—more than five times the rate of PTSD among non-HIV positive women—and about 55 percent of HIV-positive women experience intimate partner violence, which is more than twice the national rate.9 Among HIV-positive men who have sex with men (MSM), 35 percent report childhood sexual abuse.10
SUDs Among PLWH
PLWH, including those with mental disorders, have high rates of having a past or current history of a substance use disorder from alcohol or drug use. According to data from the National Survey on Drug Use and Health, approximately 28 percent of PLWH aged 12 or older reported engaging in binge alcohol use in the past month.11 Approximately 66 percent of PLWH have used illicit drugs, 16.5 percent have a history of intravenous drug use, and 24 percent of PLWH report receiving treatment for SUDs. An estimated 10 to 28 percent of PLWH have co-occurring SUDs and mental disorders. SUDs can lead to risky sexual behaviors, such as having sex without a condom and having multiple partners, behaviors that increase the risk of HIV transmission. Having a SUD also makes it difficult for PLWH to adhere to HIV treatment and attain the goal of viral suppression.12
TRAUMA-INFORMED CARE APPROACH AS PART OF INTEGRATED SERVICES
Providing sensitive and safe trauma-informed care helps to ensure the best possible health outcomes for survivors of trauma. Trauma-informed care is an approach in which providers:
- Understand the effects of past or current traumas in clients’ lives and paths for recovery
- Recognize the signs and symptoms of trauma
- Respond to the effects of trauma by integrating practices and procedures on an organizational and individual level to help treat, empower, and heal patients who have experienced or are experiencing trauma.
The Illinois Department of Public Health (IDPH), a Ryan White HIV/AIDS Program recipient, emphasizes trauma-informed care through training for case managers. “Internally at the health department, we have done a significant amount of work on reducing the silos within IDPH—on the work that we’re doing within trauma—so that we can learn from each other and collaborate with each other,” explained Elizabeth McChesney, Client Services Coordinator for IDPH’s program. IDPH added questions from the Adverse Childhood Experience module in the Behavioral Risk Factor Surveillance System to its online consumer needs assessment. The data collected ultimately help inform how IDPH provides HIV care and treatment.
RYAN WHITE HIV/AIDS PROGRAM AND INTEGRATED CARE TO IMPROVE BEHAVIORAL HEALTH OUTCOMES
PLWH benefit from comprehensive and integrated HIV care that provides access, coordination and linkages to mental health, trauma, and substance use evaluation, treatment, and services within the same system or facility. PLWH may encounter numerous obstacles to accessing behavioral health services in a traditional medical care setting, as well as poor integration of behavioral health and primary care services. These obstacles may include stigma and discrimination associated with HIV, behavioral health issues, or being part of a vulnerable population—including low-income PLWH who are uninsured and underserved, ethnic/minority populations, youth, older adults, and women—which may limit access to care and services. PLWH who have behavioral health conditions also may mistrust the medical system, which may affect their willingness to receive and maintain HIV care. Additionally, receiving behavioral care in traditional medical settings with providers who are not educated about PTSD and not trained in using a trauma-informed care approach, for example, may be distressing for PLWH who have experienced trauma and may exacerbate or trigger a negative memory to the trauma. Survivors of trauma, in particular, may also have difficulty answering intimate personal questions, removing their clothing, and having a physical exam, all of which may be perceived as invasive or threatening. They also may mistrust or be intimidated by the power dynamics of the doctor-patient relationship or the gender of the health care provider.
Unlike traditional medical systems, Ryan White HIV/AIDS Program recipients provide a comprehensive system of integrated HIV primary medical care—including specialized services using a trauma-informed care approach to respond to the effects of trauma on PLWH, case management and other essential support services, and medications—to PLWH who are uninsured and underserved. More than 550,000 people receive services through the Ryan White HIV/AIDS Program each year. Since the Program’s inception 27 years ago, Ryan White HIV/AIDS Program recipients and providers have been addressing the health needs of PLWH through a patient-centered, team-based approach that integrates and coordinates behavioral and primary medical services. This integrated model of care is uniquely equipped to identify and respond to clients’ behavioral health challenges because it allows providers to collaborate with one another and to assess and refer patients for specialized behavioral health disorder treatment within the same health care system or facility. It has further demonstrated improved health outcomes for PLWH because it increases accessibility to appropriate treatment and care, thus ultimately helping to achieve viral suppression. In 2016, approximately 85 percent of the Program’s clients achieved viral suppression—the goal of HIV care.
Features of Integrated Behavioral Health Care
Effective, integrated behavioral health care is dependent on such features as dedicated and trained staff from multiple disciplines, co-located care services, a system for screening and referral of clients for behavioral health treatment, and ongoing communication between Ryan White HIV/AIDS Program providers and clients.13, 14, 15
Multidisciplinary team. The multidisciplinary care team comprises a range of providers with well-Defined roles within the team, including primary medical practitioners and professionals—such as physicians and nurse practitioners—community health workers, peer navigators, social workers, psychiatrists, psychologists, addiction counselors, case managers, and medical assistants.
Co-located services. When primary and behavioral health services are located within the same medical system and facility—also known as a “one-stop shop” approach—or when linkages and referrals to behavioral health services are offered, clients are more likely to engage in and stay in care and receive appropriate treatment. Screening and referral for behavioral health disorders. An integrated approach to HIV care enables providers to identify and evaluate patient health care needs and refer those patients with mental health conditions, trauma/PTSD, and SUDs to trained specialists for behavioral health services. See Screening for Behavioral Health Disorders: A Critical Component of Integrated Care.
Screening and referral for behavioral health disorders. An integrated approach to HIV care enables providers to identify and evaluate patient health care needs and refer those patients with mental health conditions, trauma/PTSD, and SUDs to trained specialists for behavioral health services. See Screening for Behavioral Health Disorders: A Critical Component of Integrated Care.
Staff training. For behavioral health care to be most effective, the whole health team—from office receptionists and intake specialists to providers and peer navigators—benefits from regularly scheduled training. Staff training may focus on identifying patients with behavioral health conditions; how mental illness, trauma, and SUDs may affect the lives of clients; how to sensitively interact with clients who have experienced trauma/PTSD; and other relevant topics.
Patient engagement and empowerment. Ongoing engagement and communication between health care providers and clients build trust and also may improve behavioral health outcomes for PLWH. Clients are better able to make informed health care decisions when Ryan White HIV/AIDS Program providers share and discuss HIV care options and listen to what matters most to the patient. Other positive outcomes may include greater retention in HIV care, improving medical adherence, and lowering health care costs.
Communication among health care staff. Ongoing effective communication and collaboration among providers is vital to ensure that clients receive the care they need. Integrated care teams use informal face-to-face conversations between providers who may encounter each other in a hallway, for example, and more structured types of communication, such as daily “huddles” and weekly, biweekly, and monthly meetings to review clients’ care, treatment plans, and clinical progress. Using this approach, primary care providers and behavioral health specialists also review one another’s client notes via electronic medical records, consult with one another, and address treatment plans as needed, including medications, talk therapy, and educational interventions to help clients with HIV also manage their behavioral health conditions.
SCREENING FOR BEHAVIORAL HEALTH DISORDERS: A CRITICAL COMPONENT OF INTEGRATED CARE
Routine screening and identifying substance use and mental disorders as early as possible are critical components of integrated care. Incorporating screenings and referrals into behavioral health services can help PLWH with behavioral health conditions stay engaged in care and improve overall treatment outcomes. For example, early detection of SUDs through screening can result in timely intervention and treatment, including medication-assisted treatment, which can make a considerable difference in outcomes. The Health Resources and Services Administration’s (HRSA) HIV/AIDS Bureau (HAB) requires
Ryan White HIV/AIDS Program providers to follow the U.S. Department of Health and Human Services (HHS) Guidelines for Use of Antiretroviral Agents in Infected Adults and Adolescents. The guidelines include screening for clinical depression and substance use and, if identified, creating a follow-up treatment plan to help clients address and manage these issues. Ryan White HIV/AIDS Program providers and organizations have access to a wide variety of tools to screen for behavioral health conditions.
The Substance Abuse and Mental Health Services Administration (SAMHSA)-HRSA Center for Integrated Health Solutions (CIHS) and the Ryan White HIV/AIDS Program Part F AIDS Education and Training Center Program offer a variety of screening tools and resources to help Ryan White HIV/AIDS Program providers and organizations enhance their integrated HIV and behavioral health care approaches. These include the following:
- Depression: Patient Health Questionnaire 2 and 9 (PHQ 2 and PHQ 9)
- Anxiety Disorders: Generalized Anxiety Disorder 7 (GAD-7) question tool
- Substance Use Disorders: Alcohol Use Disorders Identification Test (AUDIT), CAGE AID, Drug Abuse Screen Test (DAS T-10), and other tools
- Trauma: Life Events Checklist and Primary Care PTSD (PC-PTSD) Screen
HIV providers also can incorporate the Screening, Brief Intervention and Referral to Treatment (SBIRT) model into their routine care. SBIRT is an evidence-based practice used to deliver early intervention and treatment to people with, or at risk for SUDs. SBIRT has three steps:
- Screening for risky substance use behaviors using standardized screening tools.
- Conducting a brief intervention or conversation between health care provider and patient about risky substance use behaviors. Provider offers feedback and advice.
- Referring patients for additional treatment based on screening results.
SBIRT was developed in response to a recommendation by the Institute of Medicine for community-based screening of behavioral health risks, including substance use.
Stories From the Field: Ryan White HIV/AIDS Program at CarePoint Health and the Center for Comprehensive Care
The Ryan White HIV/AIDS Program-funded CarePoint Health system and The Center for Comprehensive Care in Hudson County, New Jersey, provide comprehensive and integrated medical services, including behavioral health care and case management, to children, adolescents, and adults infected with HIV. CarePoint Health, which includes three area hospitals, delivers HIV health services in communities highly affected by HIV, especially among bilingual racial/ethnic minorities. CarePoint Health’s client population comprises 41 percent Hispanics, 23 percent black/African Americans, and the remaining population mainly Whites. The client population at the Center for Comprehensive Care is primarily black/African American, followed by Hispanics/Latinos, Whites, and Asians.
Both CarePoint Health and The Center for Comprehensive Care offer on-site behavioral health care and treatment services. Such medical services as psychiatry, behavioral health screening and referral, counseling, and primary care, as well as laboratory services, all are located within one setting. This comprehensive and integrated approach ensures a thorough and effective process for identifying, treating, and retaining clients. Whitney Bracco, program director for the Center for Comprehensive Care, stated, “The one-stop shop is our unique feature and is responsible for our successful program. Clients like the fact that all services are available in one location, and they do not need to go outside.”
Gustavo Valdes-Rivera, CarePoint Health director for the Ryan White HIV/AIDS Program, said, “Be very aware of the community you serve. Since we serve over 40 percent Hispanics, we have on-site bilingual program services.” CarePoint Health also provides financial aid for transportation, medications, etc., to clients in need—which is critical for keeping patients in care and improving patient outcomes. Patients referred to services are screened every six months for behavioral health conditions to identify such HIV comorbidities as depression. Appropriate follow-ups and referrals are recommended to the clients by their assigned case managers based on their screening results. According to Mr. Valdes-Rivera, “Case managers are essential to the process. They stay in close contact with patients and hold bimonthly meetings with health care providers to facilitate communication and help ensure that patients receive and stay in behavioral health care.” Mr. Valdes-Rivera stated that this “enhanced communication has led to increased medication adherence, engagement, and treatment rates among patients with behavioral health conditions at CarePoint Health.” Ms. Bracco also emphasized that case managers are essential and added, “The Center for Comprehensive Care also owes its success to having on-site behavioral health staff, such as psychiatrists, psychiatric nurse practitioners, and counselors, as well as case managers. Our collaborative, integrated approach to HIV care further aids in identifying and addressing the clients’ behavioral health disorders, making the program successful.”
Stories From the Field: The City of Milwaukee, WI
Ryan White HIV/AIDS Program at AIDS Resource Center of Wisconsin (ARCW)
ARCW has 10 statewide offices and clinics that provide a robust array of integrated services and act as medical homes to nearly 3,600 clients in the state of Wisconsin. ARCW serves a demographic consisting of 50 percent Whites, 45 percent black/African Americans, and 5 percent other demographics, with most clients living below the poverty level. Its integrated services include co-located medical, dental, and mental health clinics, along with a pharmacy, a food pantry, legal services, an HIV prevention program, and social work case management services, ensuring that PLWH thrive, not merely survive.
ARCW’s integrated approach emphasizes the need for health care teams to include physicians, nurse practitioners, nurses, dentists, mental health therapists, lawyers, nutritionists, social workers, and case managers. Dr. Kevin Roeder, senior director of behavioral services, said, “By providing integrated medical, behavioral, and social services, along with an accessible electronic health records system, we elevate coordination of care for our clients to the highest level.” The clinical liaison program ensures that a therapist for clients to talk to is available in the clinic daily. Along with screening for depression and other mental health conditions, ARCW provides neuropsychological assessments for clients aged 50 or older. Research indicates that PLWH aged 50 or older have an increased risk of neurocognitive issues associated with aging. Dr. Debra Endean, vice president and chief operating officer, emphasized the need to start with the client: “Think about your patient holistically and avoid artificial distinctions between care for the body and care for the mind: it’s care for the person.”
Stories From the Field: Prism Health North Texas, Dallas, TX
Prism Health North Texas provides HIV care services to a population comprised of nearly 60 percent racial and ethnic minorities. Its integrated behavioral health services program is successful as a result of co-locating services, according to Dr. Manisha Maskay, chief program director. “Most of the clients we serve like the one-stop shop approach since they do not have to go anywhere else to get services.” The in-house access to behavioral health counselors, psychiatrists, and mental health providers facilitates screening, treating, and retaining clients living with HIV and behavioral health conditions. In their clinics, the most common behavioral health disorders observed are major depressive disorder, post-traumatic stress disorder, and methamphetamine use disorder, according to Dr. Maskay. “Integrating behavioral health services in our program has benefited our patients in multiple ways, including attaining 90 percent viral suppression and improved medical adherence, which is very encouraging.”
Communication among the team and with the client also is very important for successful treatment and medication adherence. The staff, including the case managers and clinical providers, have regularly scheduled case conferences. Shared electronic health systems are another important aspect of the successful program. The case managers, behavioral health counselors, psychiatrists, and other team members all have access to the client’s health information, leading to better patient outcomes.
Although the program is successful, one challenge that Prism Health North Texas faces is access to and availability of trained and culturally competent behavioral health counselors, including mental health providers who thoroughly understand the environment and nature of treating people living with chronic conditions like HIV. Dr. Maskay explained, “We believe in the harm-reduction approach that employs a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. This leads to improved patient outcomes.”
- Ryan White HIV/AIDS Program Annual Client-Level Data Report, 2016 (PDF - 2 MB)
- HRSA’s Behavior Health Integration with Primary Care webpage
- SAMHSA’s Concept on Trauma and Guidance on a Trauma Informed Care Approach (PDF - 451 KB)
- SAMHSA-HRSA Center for Integrated Health Solutions information about integrated care models, behavioral health screening tools, and information for clinical practice, including trauma-informed care
- The Agency for Healthcare Research and Quality’s new report (PDF), Implementing Medication-Assisted Treatment for Opioid Use Disorder in Rural Primary Care: Environmental Scan
- Carvalhal, A. 2015. “Integrating Mental Health Care for People Living with HIV.” Health Care: Curr Rev 3:139.
- The Substance Abuse Mental Health Services Administration (SAMHSA) and The Health Resources and Services Administration (HRSA). The Case for Behavioral Health Screening in HIV Care Settings. HHS Publication No. SMA-16-4999. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2016.
- HRSA. Guide for HIV/AIDS Clinical Care. Chapter on Posttraumatic Stress Disorder. April 2014. . Accessed November 21, 2017.
- Bing, E., M. Burnam, D. Longshore, J. Fleishman, C. Sherbourne, et al. 2001. “Psychiatric Disorders and Drug Use Among Human Immunodeficiency Virus-Infected in the United States.” Arch Gen Psychiat 58:721–8. Cited in Carvalhal, 2015.
- Gaynes, B. N., B. W. Pence, J. J. Eron, Jr., and W. C. Miller. 2008. “Prevalence and Comorbidity of Psychiatric Diagnoses Based on Reference Standard in an HIV+ Patient Population.” Psychosom Med 70 (4): 505–11.
- Do, A. N., E. S. Rosenberg, P. S. Sullivan, et al. 2014. “Excess Burden of Depression Among HIV-Infected Persons Receiving Medical Care in the United States: Data from the Medical Monitoring Project and the Behavioral Risk Factor Surveillance System .” PLoS ONE 9(3): e92842.
- National Academy of Sciences. 2005. “Appendix C: Mental Illness and HIV Comorbidity: A Large and Vulnerable HIV Subpopulation.” In: Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White.
- HRSA, April 2014.
- Machtinger, E. L., T. C. Wilson, J. E. Haberer, and D. S. Weiss. 2012. “Psychological Trauma and PTSD in HIV-Positive Women: A Meta-Analysis.” AIDS Behav 16: 2091.
- Kamen C., S. Flores, and S. Taniguchi. 2012. “Sexual Minority Status and Trauma Symptom Severity in Men Living With HIV/AIDS.” J Behav Med 35(1): 38–46.
- SAMHSA, Center for Behavioral Health Statistics and Quality. 2010. “The National Survey on Drug Use and Health (NSDUH) Report: HIV/AIDS and Substance Use (PDF - 334 KB) .” 2010.
- SAMHSA-HRSA Center for Integrated Health Solutions (CIHS). 2016. The Case for Behavioral Health Screening in HIV Care Settings.
- 13. Carvalhal, 2015.
- 14. SAMHSA and National Council for Behavioral Health. 2014. Essential Elements of Effective Integrated Primary Care and Behavioral Health Teams.
- Agency for Healthcare Research and Quality. The SHARE Approach—Achieving Patient Centered Care with Shared Decisionmaking: A Brief for Administrators and Practice Leaders. Content last reviewed July 2014. Available at Agency for Healthcare Research and Quality, Rockville, MD.
HRSA CARE Action
U.S. Department of Health and Human Services
Health Resources and Services Administration, HIV/AIDS Bureau 5600 Fishers Lane, Mail Stop 09SWH03 Rockville, MD 20857
Prepared for HRSA/HAB under Contract No. HHSH250201500003A
Copies are available for download at HIV/AIDS Bureau.
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