INTRODUCTION
Cournos and colleagues provide an illuminating and thorough overview of four groups who have increased vulnerability to both HIV and mental illness: men who have sex with men, injection drug users, sex workers and people living with severe mental illness.
The authors draw attention to the multiple pathways by which HIV and mental illness interact to increase vulnerability in each of these groups. For example, injection drug use increases infection rates, and people who inject drugs are less likely to start antiretroviral (ARV) treatment. There are high rates of comorbid substance use disorders amongst this population, which further increase the risk for psychiatric disorder. Furthermore, social factors determine many of these vulnerabilities. For example, in countries where sexual behaviour amongst men is criminalized or otherwise stigmatized, elevated rates of psychiatric disorders have been reported. Similarly, sex workers are frequently poor and marginalized, with little recourse to protection from criminal justice systems in their societies, thus further exacerbating their vulnerability.
The authors highlight the enormous increase in global funding for the HIV epidemic, which grew from US$2.1 billion to US$10 billion between 2001 and 2007. However, despite this funding, mental health needs are seldom addressed amongst vulnerable populations. This neglected priority is a gap in our approach to prevention, care and treatment.
DEVELOPING MENTAL HEALTH SERVICES FOR HIV IN RESOURCE-LIMITED SETTINGS
In the light of these trends, how should mental health services for HIV be shaped and delivered in resource-limited settings? In particular, how can the needs of these vulnerable groups be met when facing the multiple challenges of reduced access, uptake and continuing care?
Cournos and colleagues describe the AIDS Support and Technical Assistance Resource (AIDSTAR-One) model of mental health care for people at risk of or living with HIV. This model is broken down into three phases:
- In the first phase (pre-ART pre-antiretroviral therapy), five needs can be identified:
- Early diagnosis of mental health and substance use disorders
- Access to HIV care for people living with mental health and substance use disorders
- Mental health needs associated with receiving an HIV diagnosis, such as anxiety, low mood and suicidal ideation
- Mental health needs related to social isolation and stigma of HIV
- Chronic care
- Early diagnosis of mental health and substance use disorders
- In the second phase (receiving ART), many of the above needs persist. In addition, there are needs associated with living with a chronic illness, including ARV adherence and management of mental illness or substance use disorder.
- The final phase (advanced disease or end of life) involves dealing with major illness and supporting family and friends through loss and possible cognitive impairment.
The authors concede that not all of these will be possible in low- and middle-income countries (LMIC) where the burden of HIV is greatest. However, they highlight a few ‘fledgling approaches’ that hold promise:
Related posts:
1.1 Epidemiology of Psychopathology in HIV: Neurocognitive Disorders
2.4 Traumatic Stressors and the Psychoneuroimmunology of HIV/AIDS
3.2 Differential Diagnosis in HIV-Associated Neurocognitive Disorders
4.2 Psychopharmacology and Psychiatric Co-morbidity
Inex
5.2 COMMENTARY Specifying the Mental Health Context for the Development of HIV Prevention and Treatment Interventions for Men Who Have Sex with Men
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