Successful HIV effort prompts call for clinics to expand mental health services on site

"With the president's 'Ending the HIV Epidemic' [goal], we need to be identifying evidence-based programs and policies that help improve HIV outcomes. This study adds to the evidence that co-located mental health services, which includes psychiatry, psychology and substance-use counseling, can contribute to improved HIV viral suppression, which is a key health metric for HIV care," said researcher Kathleen McManus, MD, of UVA's Division of Infectious Diseases and International Health. "We hope that this work will encourage more Ryan White HIV/AIDS clinics to seek support for co-located mental health and substance use counseling services."

Improving HIV Care

Seeking to improve outcomes for people living with HIV, UVA's Ryan White Clinic expanded its mental health services in 2013, increasing access to psychiatry and psychology services and substance-use counseling. Between 2012 and 2014, UVA more than doubled the number of clinic patients receiving mental healthcare. Mental health visits at the clinic increased from 385 in 2012 to 941 in 2013 and 1,183 in 2014. (UVA's ability to expand the mental health offerings was made possible by funding from the Health Resources and Services Administration Ryan White HIV/AIDS Program.)

Researchers then compared how patients fared before and after the expansion. They compared one group of 130 patients who initiated mental healthcare before the expansion and another group of 181 patients who initiated mental healthcare after the expansion to get a snapshot of who was gaining access when the availability of mental health services increased. They also examined the HIV outcomes of the patients in the latter group both before and after the expansion.

They found:

• Patients who had access to the expanded mental healthcare achieved better HIV outcomes after establishing care with a mental health provider. The rate of viral suppression -- when the virus is undetectable in the body, a key benchmark for patients' treatment and overall health -- increased from 57 percent to 88 percent.
• When mental health care services were expanded, the patients who gained access to these services were not doing as well as people who had already established mental health care. The patients who gained access were more likely to have AIDS with a low CD4 count, which shows how the immune system is functioning. They were also more likely to have a detectable viral load, meaning that their health was not optimized and that they could transmit HIV to someone else.
• Older and white patients benefited more from the increased access to mental healthcare than did other patients.
• Younger and black patients were less likely to achieve viral suppression after initiating mental healthcare, prompting the UVA researchers to question whether changes are needed in how care and other services are provided to those patients.
• The expanded mental healthcare did not significantly change patients' engagement in their HIV care measured by attending at least two HIV medical appointments within a year.
• After the expansion, more patients were diagnosed as having substance use-related diagnoses, possibly because of increased awareness and identification by the mental health providers.

Describing their findings in a new article in the scientific journal Open Forum Infectious Diseases, the UVA researchers wrote that expanding mental healthcare at HIV clinics across the country could help the U.S. reach the goal of viral suppression among 90 percent of people with HIV. That would help prevent further transmission of the disease, they noted. "It is an opportunity to improve viral suppression outcomes for vulnerable populations, and this is pressing given the worsening of the opioid and substance-use crises," they concluded.

The researchers noted that this was a small, retrospective study and called for additional research to assess if there is a causal relationship between increased access to mental healthcare and viral suppression.