Although living longer and healthier lives with modern treatment, people around the world with HIV suffer disproportionately from associated neurocognitive disorders as well as depression and substance use disorders.

Such disorders are more prevalent among HIV patients than associated physical ailments, with depression rates twice as common. In one sub-Saharan African study, 27 percent of HIV patients were drinking alcohol, three percent "hazardously," to the point of interference with their antiretroviral drug therapy for HIV. Worldwide, the occurrence of any of those disorders with HIV ranges from one-fifth to more than half of all patients — and is particularly higher in those most vulnerable, like older patients or those with advanced immunosuppression.

On Tuesday, an international team from the United States, Haiti, Uganda, and Tanzania released the first of a five-part policy report on improving HIV patient outcomes by integrating treatment for HIV and comorbid mental illnesses. The report was published in the online journal PLOS Medicine, with funding from the U.S. National Institute for Mental Health.

A variety of mechanisms link HIV with co-occurring mental illnesses, the report authors wrote, including the social conditions under which most patients live, with fears about employment and housing, food security, and social stigma. Many also fear being "outed" as HIV-positive. All of this in combination contributes to greater incidences of mental illnesses, exacerbating the physical symptoms of the disease.

Such disorders are in turn "associated with greater suffering, including poorer psychological adjustment to a chronic, progressive and life-threatening illness; lower quality of life; worse HIV treatment adherence and outcomes; and an increased likelihood of HIV transmission," the authors wrote.

On a more somatic level, HIV directly affects the central nervous system with increasing evidence of long-term cognitive problems that may not be helped by antiretrovirals, with additional risk too for contracting other infectious and non-infectious conditions exacerbating the condition of the central nervous system - including malaria, tuberculosis, and lymphomas.

The merry-go-round of HIV and comorbid conditions is well-supported by the scientific literature but missing is good clinical data on implementing programs to integrate the two modes of care, the authors wrote, particularly in clinical settings intended solely for the treatment of the HIV epidemic. While standardized HIV treatment regimens have greatly helped patients in low- to middle-income countries around the world, the report authors see significant potential in treating such ailments as depression and alcohol abuse disorder, too.

However, one of the more promising areas for improvement would be in the mitigation of impairment to functionality of the central nervous system, with the earlier use of antiretrovirals in treatment. The report authors cautioned that although the drug therapy has been shown to arrest such neurocognitive impairment, children with HIV may not achieve the same development as others.

For the treatment of psychological disorders co-occurring with HIV, proven therapies have been studied in both rich and poor countries, with varying results. Interventions for alcohol abuse disorder, for example, help greatly for patients with access to such services, with problem drinkers dying at rates 23 to 26 percent less.

"These improvements are modest but notable relative to their cots and potential widespread availability," the authors wrote. Moreover, "integrating [screenings and brief therapeutic interventions] into HIV care also provides an opportunity for assessing incremental benefits in HIV treatment outcomes due to improvements in [drug therapy treatment] adherence, fewer opportunistic infections, and fewer HIV risk behaviors as problem drinking decreases."

The case for integrating mental health care into generalized medicine is supported by a number of good studies, the authors wrote, and may be extremely practical given the commonality between the two modes of disease. "In some cases, onset of a mental disorder, such as abrupt changes in mood may be the first sign of a new or worsening medical problem," they wrote. "The ability to conduct a thoughtful, comprehensive evaluation that includes mental health may lead to more rapid and appropriate treatment for both the mental health and somatic problems."

And perhaps most important in many areas of the world, the integration of HIV care with mental health illness may increase the effectiveness of treatment for patients in poor countries, where often people miss even free mental health treatments due to lack of resources like bus fare.

The open-access report is available online.

 

 

Source: Kaaya S, Eustache E, Lapidos-Salaiz I, Musisi S, Psaros C, et al. Grand Challenges: Improving HIVTreatment Outcomes by Integrating Interventions for Co-Morbid Mental Illness. PLoS Med. 2013.