Feature

Washington, D.C., isn't just the nation's capital. It's also the nation's HIV capital, with the highest infection rate in the country.

On April 20, about 200 HIV-prevention and care providers, researchers, local and federal health officials, community- and faith-based organizations, HIV-awareness advocates and people living with HIV/AIDS came together to explore ways of addressing the city's epidemic. The conference, "Advancing the National HIV/AIDS Strategy in Metropolitan Washington: Science-Practice Partnerships," was sponsored by APA, Howard University and the Office of Behavioral and Social Sciences Research at the National Institutes of Health (NIH).

For APA, the forum had an additional objective: ensuring that prevention efforts include behavioral as well as biomedical interventions.

"It's absolutely clear that social determinants and environmental factors must be addressed if we're going to make a real impact," said Gwendolyn P. Keita, PhD, executive director of APA's Public Interest Directorate. "APA has worked steadily to make sure that psychology informs efforts at the federal, state and local levels to achieve the goals of the National HIV/AIDS Strategy."

Behavioral factors

The National HIV/AIDS Strategy has three goals: reducing HIV incidence, increasing access to care and optimizing outcomes, and reducing HIV-related health disparities in the United States.

Achieving those goals will require better integrating psychology into the response to HIV/AIDS, said Ronald O. Valdiserri, MD, deputy assistant secretary for health and infectious diseases at the U.S. Department of Health and Human Services, citing APA's new resolution on combining biomedical and behavioral approaches (PDF, 83KB) to optimize HIV prevention.

"APA's resolution reminds us that there is no magic bullet and no single approach — whether biomedical, behavioral, structural or legislative — that's going to end this epidemic in the U.S.," he said. "Instead, what we need to do is strengthen the linkages between the biomedical and the behavioral."

To reduce new infections, health-care providers must address the psychological factors — such as fear of testing positive — that keep people from seeking a diagnosis, said Valdiserri. To increase access to care, providers must address issues of stigma, he said, citing one survey of men who have sex with men that found that fewer than half had talked about their sexual practices with their health-care providers. To reduce disparities, prevention efforts must address the social determinants of health, such as intimate partner violence and sexual abuse of women.

Noting that less than a third of the 1.2 million Americans infected with HIV have their infections under control, Valdiserri called upon participants to ease the way for Americans to get tested, connect with care and stay on antiretroviral therapy. Permanent housing with intensive case management and peers who can help patients navigate the health-care system and thus get into care and stay there could help, he concluded.

Intertwining epidemics

HIV infection is often just one of the problems the HIV-positive face, said psychologist David Holtgrave, PhD, chair of the health, behavior and society department at the Johns Hopkins Bloomberg School of Public Health.

Urban gay men, for example, also have very high rates of distress, depression, attempted suicide, childhood sexual abuse, substance abuse and partner violence. These issues complicate and worsen the HIV crisis, said Holtgrave.

"If you look at recent sexual behavior that could put one at risk of HIV transmission or infection, there's a strong relationship between risk behavior, HIV prevalence and a number of psychosocial health issues," he said.

Prevention efforts must simultaneously address all these challenges while also taking a lifespan perspective, Holtgrave said. Early life experiences, such as parental abuse, homophobia and school bullying can make people more vulnerable to HIV later in life, he said.

That said, Holtgrave added, most people with multiple psychosocial challenges don't contract HIV.

"When we're thinking about developing interventions, we need to build on strengths and learn lessons from those who have addressed a number of these challenges," he said.

In addition to supporting behavioral changes people are already making, prevention efforts should also remove barriers that keep people from making changes they want to make and achieving resilience. In one Washington, D.C., project, for instance, women were motivated to use female condoms but couldn't until they were trained how.

Revamping systems

But it's not enough to change individuals' behavior: The health-care system must also keep up with emerging science about the psychological factors that influence disease, said psychologist Robert M. Kaplan, PhD, director of the Office of Behavioral and Social Sciences Research at NIH.

One hundred years ago, he said, the idea that germs caused almost all disease dominated the health-care system, which responded by building hospitals and training residents to fight germs. In the 1960s, epidemiological advances revealed that risk factors such as high blood pressure or cholesterol could also cause problems, and the health-care system oriented itself to identify factors that cause chronic disease.

"Science has moved on again," said Kaplan. Now, there's a new understanding that social and environmental factors also play a critical role in determining health outcomes. "The difficulty is that we're still running a health-care system that doesn't recognize that quite yet," said Kaplan.

The nation also needs to invest much more heavily in public health, said Kaplan. Despite the increased life expectancy that past public health initiatives have brought, he said, the public health system is now severely underfunded. A 2012 Institute of Medicine report, "For the Public's Health: Investing in a Healthier Future," offers one potential solution: taxing health-care transactions.

"That's a remarkably gutsy thing to say in an era when people say that anything that involves the word ‘tax' is dead on arrival," said Kaplan.

Recommendations

The conference's second half was devoted to small-group discussions aimed at developing recommendations for the D.C. Department of Health, D.C. Department of Mental Health, District of Columbia Development Center for AIDS Research, Center for AIDS Research at NIH and others.

Recommendations included expanding prevention messages and testing to older adults and others who aren't traditionally considered high risk; focusing more on helping people who test negative to stay that way; investing resources in housing, mental health services and substance abuse treatment to help people stay in care; and developing "red carpet care" in which peers would offer advice, accompany patients to appointments or even provide intensive case management. Participants also called for developing a website that would bring together information on all types of services — HIV/AIDS, housing and mental health programs, for example — all in one place.

Participants also urged their colleagues to find ways to overcome the stigma associated with HIV. One possibility is establishing "ubiquitous care," which would allow patients to pick up their medications at drop-in centers or other places besides HIV clinics, said psychologist Ellen Stover, PhD, a senior policy leader at the National Institute of Mental Health.

"It doesn't say HIV or infectious disease, so there's not the stigma," said Stover.

Another strategy would be to start treating HIV like other chronic diseases by incorporating exercise and good nutrition into treatment regimens, she said.

The D.C. Department of Health will consider all the recommendations, said Director Mohammad N. Akhter, MD, adding that some efforts are already under way.

For example, the city is developing patient-centered medical homes for HIV, which will bring HIV, mental health, substance abuse, social services and other programs together on one campus, he said. Other priorities include exploring ways technology can improve prevention efforts and treatment adherence and improving cultural competence among health-care providers.


Rebecca A. Clay is a writer in Washington, D.C.