Overview of HIV Integrated Care


Those on the front lines of HIV prevention and care often struggle with handling clients who are dealing with mental health and substance abuse problems, as well as HIV/AIDS:

  • Nearly 50 percent screened positive for mental health disorder
  • Nearly 40 percent reported illicit drug use other than marijuana
  • More than 12 percent screened positive for drug dependence (Bing et al., 2001)

The APA Office on AIDS has compiled information on this critical topic of co-occurring disorders. It is our hope that these resources will be helpful to those seeking a comprehensive and integrated approach to care and prevention. 

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For technical and capacity building assistance in integrating mental health, substance abuse and HIV prevention care, contact us.

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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