The comorbidity of HIV and a serious mental illness such as bipolar disorder or schizophrenia presents multiple challenges for patients and clinicians. Risk factors for HIV acquisition, issues related to treatment engagement — including the choice of therapeutic regimens and medication adherence — and stigma associated with both conditions all complicate the treatment of this population.
Emerging evidence suggests, however, that a collaborative approach to care — with HIV treatment and mental health services offered together in one location — may be a viable, effective strategy for managing these patients.
Michael B. Blank
“The questions about what comes first [HIV or mental illness] is a difficult one,” Michael B. Blank, PhD, told Infectious Disease News. Blank is affiliated with the HIV Prevention Research Division and serves as associate professor of psychology in psychiatry at the Perelman School of Medicine at the University of Pennsylvania. “It’s bidirectional.”
Both Blank and Conall O’Cleirigh, PhD, assistant professor of psychology at Harvard Medical School and director of behavioral medicine at Massachusetts General Hospital, identified the time at which illnesses like schizophrenia and bipolar disorder first present — late adolescence and early adulthood — as a contributing factor to the higher prevalence of HIV in this population.
“That’s usually the time when the person is first majorly stressed out,” O’Cleirigh said. “Those can be times when people are very vulnerable to HIV, particularly young gay and bisexual men. The difficulty with mental health issues is that they’re not just associated with an increased risk for risky sex that might expose them to HIV. They’re also related to a lot of other things that are related to increased risk for HIV, like substance abuse and homelessness. A lot of people who aren’t successfully in treatment for their mental health issues may well be self-medicating.”
Individuals with a serious mental health issue often lead “chaotic lives,” according to Blank, and homelessness is common for these patients, which may lead to using sex as payment for food or a place to stay.
Further complicating matters is the fact that these patients “don’t even necessarily define themselves as trading sex,” he continued. “They’re just having sex with the person who’s letting them sleep in their apartment or on their couch or feeding them. They don’t even necessarily conceptualize themselves as being at risk or engaging in sex work.”
Stigma, untreated mental illness complicate HIV care
Up to 23% of patients with a serious mental illness are estimated to have HIV, and treatment of coinfected patients is complex, according to Blank and O’Cleirigh. Undertreatment, or lack of treatment, of a mental health issue can affect adherence to ART, they said, and stigma also plays a role.
“Depression does its damage through withdrawal,” O’Cleirigh said. “People don’t just withdraw from pleasurable activities with their friends and families. They also withdraw from their own health care and from sustaining relationships with their providers. On the other end, people who are dealing with a full-blown manic episode feel so good that they think there can’t be anything wrong with them.”
Similarly, individuals with schizophrenia who experience psychotic episodes “are not going to be reliably identifying themselves as people who need to care,” according to O’Cleirigh. These patients also may be suspicious and distrustful of providers and the medications prescribed to them.
The data regarding treatment adherence among patients with HIV and mental health illness are not definitive. A systematic review of 82 reports, published in 2012, found an association between depression and nonadherence to ART, but data pertaining to the impact of other specific mental disorders such as anxiety, bipolar, psychotic and personality disorders on treatment adherence were “insufficient and inconsistent,” researchers said.
Anecdotal evidence shows that patients with a serious mental illness actually may be more adherent to ART.
“People presume that patients with severe mental illnesses are going to be less adherent to ART,” Blank said. “There is some evidence that they may actually adhere as well as others. People have had an acute exacerbation of a severe mental illness and are admitted to inpatient psychiatric units and still have undetectable viral loads. And we would not have thought that initially.”
Treatment for serious mental illnesses itself may partially explain increased adherence to ART, according to O’Cleirigh.
“The treatment cascade for HIV is complex. The treatment cascade for bipolar disorder is also pretty complex,” he said. This may enable patients who are effectively managing a serious mental illness to utilize those skills in managing HIV.
Stigma is another “really important and central issue” in the treatment of patients with both conditions, according to O’Cleirigh. Individuals may feel stigmatized by the people around them and have personal opinions that reflect stigmatized attitudes about HIV and mental illness.
“Stigma can really get in the way of moving forward in an adaptive way of looking after yourself and keeping yourself safe and engaged in care — not just HIV care but mental health care as well,” O’Cleirigh said.
Mental illness is associated with its own stigma, as is HIV. As a result, the impact of stigma may be compounded among comorbid patients.
“People often assume that, because people with mental illnesses are stigmatized, they can’t feel additional stigma for having HIV,” Blank said. “I don’t think that’s true. I think that there are separate and interacting stigmas for both mental illness and HIV.”
Treatment requires multidisciplinary, long-term strategy
An integrated approach to treatment, where physical and mental health care are delivered together, may be the most effective tactic for managing these patients.
Bruce R. Schackman
“I think the barrier, in many places, is that care is not integrated physically,” said Bruce R. Schackman, PhD, the Saul P. Steinberg Distinguished Professor of Healthcare Policy & Research at Weill Cornell Medicine and Director of the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH). “And the provision of benefits is not integrated. In many cases, insurance benefits for mental health are administered separately from medical benefits.”
The results of two recent studies highlight the promise that this approach may have for these patients.
Blank and colleagues conducted a study examining the efficacy of community-based care management for patients with HIV and serious mental health illnesses, coordinated by an advanced practice nurse for 12 months. The positive outcomes observed in the intervention group, which included reductions in viral load as well as improvements in CD4 count and health-related quality of life, were sustained at 24 months.
Project Hope was a three-arm randomized controlled trial conducted among patients with HIV and substance abuse issues who were not fully engaged in care. The study evaluated 6 months of patient navigation or patient navigation plus contingency management vs. treatment as usual with the aim of increasing viral suppression rates at 12 months. The patient navigation group participated in sessions in which navigators encouraged treatment for HIV and substance use and provided “instrumental support,” including scheduling and attending appointments with patients. Participants in the patient navigation plus contingency management group received navigation as well as a financial incentive of up to $1,160 for target behaviors, including attending visits for HIV care, picking up medications, receiving substance abuse treatment, providing drug-free urine samples and achieving viral suppression.
Results demonstrated the short-term efficacy of both patient navigation and patient navigation plus contingency management, but the impact was temporary and not maintained at 12 months.
“We wouldn’t expect a diabetic who has mental illness and is homeless to be able to manage all those issues on their own 6 months after we started giving them insulin. The results of the Project Hope trial showed that you need ongoing, intensive support for patients with HIV and a serious mental illness or substance use disorder to keep them engaged,” Schackman said.
O’Cleirigh emphasized the importance of distress tolerance, emotion regulation and social support for these patients, as well as the use of integrated health care teams.
“That kind of approach has some really good promise, where you have a therapy model that’s focused on the most relevant mental health issue and also provides counseling and skills-based training for the health issue. These general things can cut across many of the mental health diagnoses and also provide really excellent platforms for teaching skills to promote, and obtain, health.” – by Julia Ernst, MS
Blank MB, et al. AIDS Behav. 2013;doi:10.1007/s10461-013-0606-x.
Blank MB, et al. Curr HIV/AIDS Rep. 2013;doi:10.1007/s11904-013-0179-3.
Metsch LR, et al. Abstract 27. Presented at: Conference on Retroviruses and Opportunistic Infections; Feb. 22-25, 2016; Boston.
Springer SA, et al. AIDS Behav. 2012;doi:10.1007/s10461-012-0212-3.
Disclosures: Blank, O’Cleirigh and Schackman report no relevant financial disclosures.