Overview of HIV Integrated Care

Mental health and substance abuse both negatively impact HIV outcomes

Integrated care combines HIV primary care with mental health and substance abuse services to provide a single coordinated treatment program, rather than fragmented and often hard to navigate system. It addresses the various clinical complexities – whether mental health, substance abuse and/or HIV care — associated with having multiple needs and conditions in a holistic, easily accessed manner.

Mental health and substance abuse both negatively impact HIV outcomes. The co-occurrence of mental health and substance abuse increases a person’s risk for HIV nearly 12 times more than those without (Hoff et al., 1997).

A triple diagnosis impairs a person’s well-being and quality of life significantly. Patients with triple diagnosis often have higher levels of distress and physical impairment compared to individuals with no diagnosis, or a psychiatric, or a substance use disorder alone (Lyketsos, et al., 1994). The interaction between the mental health and substance abuse problems escalate both the level of risk, and the severity of HIV (Stoff et al., 2004).

HIV infection increases a person’s risk for various psychiatric disorders and substance use disorders. Not only does having a psychiatric disorder or substance abuse problem affect adherence to antivirals when occurring alone, but when they co-occur they lead to decreased adherence. For those who are consistent with their medication regimens, the HIV antiviral regimens themselves often precipitate or worsen psychiatric symptoms, inhibiting positive health outcomes (Douaihy et al., 2003). These issues underscore the need for early diagnosis and treatment in order to reduce mental illness, substance use, slow HIV disease progression and decrease mortality (Ickovics et al., 2001).

Four out of five people with a treatable and debilitating mental health disorder do not receive effective treatment

Individuals with triple diagnosis rarely receive adequate, flexible and integrated care incorporating and coordinating treatment for all three illnesses. Instead, they are subject to “one-size-fits-all” systems of care that are inadequate to meet the complex needs of this population. Clinicians treating triple diagnosis should view it as a unified diagnosis comprised of three intertwined conditions.

Need to treat the whole person, not simply parts of the person or their individual illnesses

Successful care of individuals with triple diagnosis requires integrated treatment: a holistic approach provided by an interdisciplinary, culturally sensitive clinical team, including case managers, social workers, medical providers, counselors or therapists, and psychiatrists who share a coordinated treatment plan. Optimally, medical, dual diagnosis and psychosocial services should be easily accessible at the same location.

Integrated care should include:

• Access to ancillary services;
• Multidisciplinary provider collaboration;
• Client-centered approach; and,
• Substantial efforts to connect patients to case management services to address a variety of psychosocial needs (homelessness, poverty and treatment adherence).

The approach also includes efforts to:

• Enhance family and peer support;
• Involve patients in self-help programs;
• Provide education about the interactions among the disorders;
• Offer behavioral interventions to mediate problematic behaviors;
• Improve problem-solving skills;
• Prevent relapse for both psychiatric illness and substance use; and,

• Initiate group and individual therapy as appropriate.

Any targeted HIV prevention should include both sexual and substance abuse risk reduction approaches that factor in mental health treatment

There is a “triple stigmatization” associated with having HIV, a psychiatric illness and a substance use disorder. Stigma results in the extreme marginalization of this population and further reduces self-esteem, often precipitating self-destructive behaviors and potentially delaying or undermining treatment. The perception of some health care providers that substance use or mental health problems are indicators of character flaws or moral weakness, rather than treatable medical conditions, is an important manifestation of triple stigmatization.

Barriers to integrated care include:

• Complex psychosocial conditions such as poverty, lack of health care insurance, limited social support, unstable housing and vacillating levels of motivation for change;
• Fragmented care paradigm;
• Health care provider lack of understanding how other professionals work leading to miscommunication and inadequate care;
• Lack of coordination among medical, psychiatric and substance abuse treatment and a reduction in the flexibility of care due to underfunding;
• Adequate space for new programs;
• Restrictions imposed by Medicare; and,

• Staff-related challenges including provider conflict of interest, lack of training or politics.

Organizations that provide integrated care are more responsive to their clients’ needs and play an important role in improving health outcomes

For free assistance to help you develop a plan meet the needs of your clients through integration of services, contact us.

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Disclaimer: This site contains HIV prevention messages that may not be appropriate for all audiences. If you are not seeking such information or may be offended by such materials, please exit this website.

Presentations

• Patient-Centered Medical Homes and Integrated Care
  The APA Office on AIDS hosted a Brown Bag Lunch and Learn on Oct. 16, 2013, which featured Michael Horberg, MD, MAS, FACP, AAHIVS, who presented on the topic, "Patient-Centered Medical Homes and Integrated Care", specifically as they relate to HIV disease. Horberg is the national director of HIV/AIDS for Kaiser Permanente and the executive director of research at the Kaiser Mid-Atlantic Permanente Research Institute. He served on the Presidential Advisory Committee on HIV and AIDS (PACHA) from 2010 to 2012.

• HIV Integrated Care curriculum (PDF, 2.54MB)
  Integration of Mental Health, Substance Abuse and HIV: Connections with High Impact Prevention
  
  The Behavioral and Social Science Volunteer (BSSV) program attended and participated in the 16th annual U.S. Conference on AIDS in Las Vegas, NV (Sept. 30 - Oct. 3, 2012). The BSSV program was featured in two presentations, the first of which highlighted its HIV Integrated Care curriculum: Integration of Mental Health, Substance Abuse, and HIV: Connections with High Impact Prevention. The second presentation was given by Dr. Kimberly Parker, a BSSV Program volunteer, who is currently leading the BSSV Program's evaluation capacity building assistance for the Texas Black Women's Initiative: Addressing the Impact of HIV among Black Women in Texas through Capacity-Building, Community Mobilization, and Strategic partnerships. The conference, attended by over 3,000 people, gave the BSSV program an opportunity to share information on how to access free capacity building assistance services for community based organizations that are implementing HIV Prevention programs.

• Integrating Mental Health and Substance Abuse Care with HIV/AIDS Prevention
  Learn how Colorado instituted this integration, and how you can too.
  
  In collaboration with Colorado’s Department of Health, the APA Office on AIDS created a program that provides an overview of the issues of mental health, substance abuse, and HIV prevention. The program provides real-world examples, as well as lessons learned, from the Colorado Department of Health’s integration team.

• Managing Adverse and Emotional Reactions (PDF, 1.3MB)
  Sometimes during the Post-Test Counseling session, clients adversely react to receiving preliminary positive HIV results. This training was designed at the request of a community based organization to strengthen CTR staff skills in de-escalating tense situations with clients, self-manage their emotional responses during the interaction, and use proven strategies that are useful for successfully engaging clients who test positive into care.

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Research

This page summarizes the research done under the topic of integrated care. To effectively prevent HIV, front line providers must learn to effectively identify and refer clients with mental health and substance abuse disorders.

Anderson, J. (2005). [Mental Health Issue Brief]. HIV and mental health: The challenges of dual diagnosis. NASTAD. 1-15. Retrieved from: http://www.nastad.org/Docs/Public/InFocus/200632_NASTAD_Mental_Health_final.pdf

Asch, S.M., Kilbourne, A.M., Gifford, A.L., et al. (2003). Under diagnosis of depression in HIV: Who are we missing? Journal General Internal Medicine. 78, 450-460. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1494868/pdf/jgi_20938.pdf

Bing, E.G., Burnam, A., Longshore, D., Fleishman, J.A., Sherbourne, C.D. … & Shapiro, M. (2001). Psychiatric disorders and drug use among human immunodeficiency virus-infected adults in the US. Archives General Psychiatry, 58, 721-728. Retrieved from http://archpsyc.ama-assn.org/cgi/reprint/58/8/721.pdf

Black, R.A., Serowik, K.L., & Rosen, M.I. (2009). Associations between impulsivity and high risk sexual behaviors in dually diagnosed outpatients. The American Journal of Drug and Alcohol Abuse, 35, 325-328. Retrieved from http://informahealthcare.com/doi/pdf/10.1080/00952990903075034

Blank, M.B., Mandell, D.S., Aiken, L., & Hadley, T.R. (2002). Co-occurrence of HIV and serious mental illness among Medicaid recipients. Psychiatric Services, 53(7), 868-873. Retrieved from: http://www.ps.psychiatryonline.org/cgi/reprint/53/7/868

Brief, D.J., Bollinger, A.R., Vielhauer, M.J. Berger-Greenstein, J.A., Morgan, S.M., … & Keane, T.M. (2004). Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes. AIDS Care, 16(1), 97-120. Retrieved from: http://www.informaworld.com/smpp/section?content=a713937420&fulltext=713240928

Burnam, M.A., Bing, E.G., Morton, S.C., Sherbourne, C., Fleishman, J.A., … & Shapiro, M.F. (2001). Use of mental Heath and substance abuse treatment services among adults with HIV in the United States. Archives of General Psychiatry, 58, 729-736. http://archpsyc.ama-assn.org/cgi/reprint/58/8/729.pdf

Devieux, J.G., Malow, R., Lerner, B.G., & Dyer, J.G. (2007). Triple jeopardy for HIV: Substance using severely mentally ill adults. Haworth Press. Retrieved from: http://jpic.haworthpress.com.

Klinkenberg, W.D., & Sacks, S. (2004). Mental disorders and drug abuse in persons living with HIV/AIDS. AIDS Care, 16(1), 22-42. Retrieved from http://www.informaworld.com/smpp/616565703-30555675/content~db=all~content=a713937416~frm=abslink

Meade, C.S., & Sikkema, K.J. (2005). HIV risk behavior among adults with severe mental illness: A systematic review. Clinical Psychology Review, 25, 433-457. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2559926/

Rand Health. (2007). Mental health and substance abuse issues among people with HIV: Lessons from HCSUS. [Research Highlights.]. Retrieved from: http://www.rand.org/pubs/research_briefs/2007/RAND_RB9300.pdf

Sikkema, K.J., Watt, M.H., Drabkin, A.S., Meade, C.S., Hansen N.B., & Pence, B.W. (2009). Mental health treatment to reduce HIV transmission risk behavior: A positive prevention model. AIDS Behavior, 14, 252-262. Retrieved from: http://www.springerlink.com/content/jl4001303t328762/fulltext.pdf

Soto, T.A., Bell, J. & Pillen, M.B. (2004). Literature on integrated HIV care: a review. AIDS Care, 16(1), 43-55. Retrieved from: http://pdfserve.informaworld.com/119114_750426156_713937417.pdf

Sullivan, G., Koegel, P., Kanouse, D.E., et al. (May 1999). HIV and people with serious mental illness: The public sector’s role in reducing HIV risk and improving care. Psychiatric Services, 50(5), 648-652. Retrieved from: http://psychservices.psychiatryonline.org/cgi/reprint/50/5/648

Tucker, J.S., Kanouse, D.E., Miu, A.,  Kogel, P., & Sullivan, G. (2001). HIV behaviors and their correlates among HIV-positive adults with serious mental illness. AIDS and Behavior, 7(1), 29-40. Retrieved from: http://www.springerlink.com/content/h4g82685r87188j0/fulltext.pdf

Turner, B.J., Fleishman, J.A., Wenger, N., London, A.S., et al. (2001). Effects of drug abuse and mental disorders on use and type of antiretroviral therapy in HIV-infected persons. JGIM, 16, 625-633. Retrieved from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495260/pdf/jgi_00807.pdf

Walkup, J., Blank, M.B., Gonzalez, J.S., Safren, S., Schwartz, R., …  Schumacher, J.E. (2008). The impact of mental health and substance abuse factors on HIV prevention and treatment. JAIDS, 47(1), S15-S19. Retrieved from: http://www.medscape.com/viewarticle/575869

Whetten, K., Reif, S., Ostermann, J., Pence, B.W., Swartz, M., … & Bouis, S. (2006). Improving health outcomes among individuals with HIV, mental illness, and substance abuse disorders in the Southeast. AIDS Care, 18(6), 18-26. Retrieved from http://www.informaworld.com/smpp/616565705-52617837/content~db=all~content=a755212074~frm=abslink (PDF, 149KB)

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Best Practices

• Screening, Brief Intervention and Referral to Treatment (SBIRT) Model screens persons with substance use disorders and offers a brief intervention on increasing insight and awareness regarding substance use and motivation toward behavioral change. It also helps connect persons with services needed with treatment referrals.

• SBIRT Colorado — A comprehensive, integrated, public health approach based on universal screenings, SBIRT creates awareness about America's number one preventable health issue — substance abuse.

  • Standardized screenings serve as a powerful education tool about the health consequences of substance use;
  • Alcohol and other drug use can affect a person’s health and general well-being, and research shows SBIRT can motivate people to change their behavior;
  • Proven to reduce the number of people who move from substance use to abuse and addiction; and,

  • The benefits of the practice extend well beyond the user — to family, employers, law enforcement and the health care industry

• Missouri Department of Health: Integrated Care for Individuals with HIV/AIDS, Mental Illness, and/or Substance Abuse Problems — The Missouri Department of Health project provided numerous services for persons with HIV/AIDS who had mental health and/or substance abuse issues. It was originally hypothesized that HIV/AIDS clients who were dually or triply diagnosed would have better medical, psychiatric and/or substance abuse treatment outcomes if enrolled in a coordinated and integrated system of care, as opposed to parallel systems. Thus, the goals of the project were:

  • To develop and evaluate the effectiveness of a coordinated system of care;
  • To initiate collaboration between the Missouri Department of Health and the Missouri Department of Mental Health to create and implement a comprehensive integrated model of care, which consisted of both health and mental health services for multi-diagnosed individuals living with HIV/AIDS, mental illness, and/or substance abuse; and,

  • To establish advisory committees comprised of service providers from the three systems (HIV/AIDS, substance abuse, mental health) to identify and assess the training needs of their communities and the service needs of multidiagnosed individuals residing there.

• Motivational Interviewing (PDF, 430KB)
  A great comprehensive introductory and refresher course on Motivational Interviewing (MI) techniques for daily use during client engagement into services. This training introduces the MI fundamental processes and supports participants as they develop and strengthen their ability to apply the principles during daily interactions with clients.

• Harm Reduction

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Mental Health and Substance Abuse Screening Instruments

• The Substance Abuse and Mental Illness Symptoms Screener (SAMISS) is easily administered within a number of health settings and specifically screens for both mental illness symptoms and substance use problems.

  1. SAMISS form (PDF, 70KB)

  2. Research for using SAMISS for Persons with HIV. "Brief Mental Health and Substance Abuse Screener for Persons with HIV" (PDF, 95KB).

  3. Research for using SAMISS for integration purposes. "Validation of a Brief Screening Instrument for Substance Abuse and Mental Illness in HIV-Positive Patients" (PDF, 264KB).

Mental Health Screening Instruments

• The Client Diagnostic Questionnaire can be used by service providers to identify the client’s needs for formal mental health assessment and treatment.   

  1. HRSA’s Use of Client Diagnostic Questionnaire (CDQ) Training Manual (PDF, 3.6MB) will help staff (particularly those with no mental health training) screen clients for depression, anxiety disorder including PTSD, and psychosis, as well as alcohol or drug abuse or dependence. The questionnaire is available on page 86 of the training manual.

  2. The original research, "Development and validation of the Client Diagnostic Questionnaire (CDQ): A mental health screening tool for use in HIV/AIDS service settings." (PDF, 114KB)

• The M-3 is a tool used for screening multiple common psychiatric illnesses, including bipolar disorder and PTSD.

  1. The M-3  form (PDF, 150KB) 

  2. The original research, "Feasibility and diagnostic validity of the M-3 checklist: a brief, self-rated screen for depressive, bipolar, anxiety and posttraumatic stress disorders in primary care." (PDF, 259KB)

• The PhQ-9 is a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression. This questionnaire was developed, and is property of Pfizer Incorporated.

  1. The PHQ-9 form (PDF, 44KB)

  2. The original research, "The PHQ-9: Validity of a brief depression severity measure." (PDF, 706KB)

Substance Abuse Screening Instruments

• The Alcohol, Smoking, and Substance Involvement Test (ASSIST) was developed by the World Health Organization. It helps detect and manage substance use and related problems. It was originally developed to be used in primary and general medical care settings.  

  1. ASSIST Screening Tool (PDF, 84KB)

  2. The original research "Validation of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) and Pilot Brief Intervention: A technical Report of Phase II Findings of the WHOS ASSIST Project." (PDF 1.3MB)

• The Drug Abuse Screening Test (DAST) is a self-report, 28-question screening tool that has been used for over 30 years. It is often used in conjunction with the CAGE Questionnaire.  This questionnaire is a simple four-question self test that can raise a client’s awareness about their use or abuse of alcohol specifically.

  1. DAST (PDF, 76KB)

  2. CAGE (PDF, 79KB)

  3. "The CAGE Questionnaire for Detection of Alcoholism: A remarkably useful but simple tool"  

• Project CORK: Clinical Tools lists screening tools designed for substance abuse screening including AUDIT, MAST, CAGE, CRAFFT, T-ACE and Trauma Index screening tools.

• The Alcohol Use Disorders Identification Test (AUDIT) was developed by the World Health Organization. It is a simple screening tool to assess excessive drinking. The questionnaire is available on page 32 of the training manual.

  • Alcohol Use Disorders Identification Test (AUDIT) (PDF, 170KB)

• DSM-IV Diagnostic Criteria Substance Use Disorders (PDF, 8KB) summarizes criteria of American Psychiatric Association for the diagnosis of substance abuse and dependence.

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HIV Integrated Care Trainings

Mental health issues and substance use delays HIV testing and negatively affects HIV treatment adherence and treatment outcomes. HIV infection can also increase the risk for mental health conditions and substance use, making it even more difficult to engage and retain those most in need of services.

These two- or three-day trainings increase participants' proficiency in developing sustainable partnerships with their HIV clients with co-occurring disorders in order to:

• More effectively link them to needed services
• Assist them in engaging in and staying in care
• Effectively motivate adherence to treatment regimens
• Assist program administrators in developing user-friendly service systems that minimize stigma

Who Should Participate

Program managers, case managers, clinicians, mental health providers and other key CBO staff. A minimum of 18 attendees participating in the full training is required. For additional information please contact Danielle Pope.

Calendar of Events

Training Events Calendar (TEC) is a web-based registration system for trainings and workshops which allows users to:

• Search/view CDC-sponsored trainings and workshops
• Register for CDC-sponsored trainings and workshops
• Submit trainings and workshops for posting (CDC partner agencies only)
• Search/view CDC partner agency trainings and workshops
• Connect to selected partner agency registration sites
  

Fact Sheets

UCSF Center for AIDS Prevention Studies. AIDS Research Institute fact sheets

• "How does mental health affect HIV Prevention?" (PDF, 725KB) (2001) 

• "What are substance abusers’ HIV Prevention needs?" (PDF, 50KB) (1996) 

• "What are injection drug users’ HIV Prevention needs?" (PDF, 724KB) (2003)

SAMSHA National Mental Health Information Center fact sheet

• Mental Health and HIV (PDF, 247KB) (2005)

Other Resources

• National Registry of Evidence Based Programs and Practices (NREPP) is a searchable database of interventions for the prevention and treatment of mental and substance use disorders. SAMHSA has developed this resource to help people, agencies, and organizations implement integrated programs and practices in their communities.

• National Alliance on Mental Illness (NAMI) explains the importance of integrated treatment of mental illness and substance abuse disorder. NAMI describes the critical components of an integrated approach.

• American Psychological Association (APA) recommends that additional funding be provided for mental health and substance abuse services for persons living with HIV/AIDS in their report, Increased Mental Health and Substance Abuse Services Needed For Persons Living with HIV/AIDS.

• AIDS Education Training Center conducts targeted, multidisciplinary education and training programs for health care providers treating persons living with HIV/AIDS. This website provides a central repository for AETC program and contact information and for training materials developed within the AETC network.

• The American Psychological Association’s capacity building assistance program, Behavioral and Social Scientist Volunteer (BSSV) Program is a national HIV prevention technical assistance program directed by the APA Office on AIDS.

• National Alliance of State and Territorial AIDS Directors (NASTAD) is a site that offers information to help bridge the gaps between science, policy and public health.  The site offers a variety of resources for HIV prevention, care and treatment, HIV policy, HIV advocacy, etc.

• Office of HIV Psychiatry recognizes that mental and neurological disorders have an intertwined relationship with HIV and AIDS and the important role that psychiatrists play in preventing the spread of HIV. To help meet these clinical challenges education and training, clinical resources, technical assistance, policy guidance, and a network of clinical expertise on the mental health dimensions of HIV/AIDS are available on this site. 

• The Substance abuse and infectious disease: Cross training for collaborative systems of prevention, treatment and care initiative provides training and technical assistance to organizations to enable more effective collaboration while serving individuals with concurrent substance abuse problems and/or infectious diseases such as HIV/AIDS.

HIV Guidelines

• The Centers for Disease Control and Prevention published the revised guidelines for HIV counseling, testing, and referral in the 2001 MMWR.

• HIV Clinical Resource offers current clinical guidelines, quality of care information, clinical education and a variety of resource materials for public use.

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