UNAIDS and the World Health Organization (WHO) have released a new publication titled “Integration of mental health and HIV interventions — Key considerations”. It emphasizes the importance of integrating HIV and mental health services and other interventions, including linkages to social protection services, for people living with HIV and other vulnerable populations.
There is a vicious cycle between mental health conditions and HIV infection.
- Mental health conditions increase the risk of HIV infection, and people living with HIV have an increased risk of mental health conditions.
- Furthermore, mental health conditions are associated with lower retention in HIV care, increased risk behaviours and lower engagement with HIV prevention.
Our publication successfully brings together tools, best practices, case studies and guidelines that can help countries and facilitate the integration of interventions and services to address the interlinked public health challenges of mental health and HIV, all while improving access to care for persons who are the most vulnerable, such as adolescents and key populations,” said Meg Doherty, Director, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO, as per the UNAIDS website.Meg Doherty, Director, Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, WHO
Key considerations for integrating mental health and HIV interventions
This publication is mainly for national and local policy-makers; global, regional, country, and local program implementers; organizations working in and providers of health, HIV, mental health, and other relevant services; civil society; and community-based and community-led organizations and advocates.
It brings together and refers to existing HIV and mental health, psychosocial support, and other service provision guidelines, recommendations, and tools, including:
- The WHO Mental Health Gap Action Programme (mhGAP) intervention guide and the mhGAP operations manual;
- WHO, United Nations Office on Drugs and Crime (UNODC) and other guidelines and tools related to substance use, including alcohol; and
- WHO consolidated guidelines, tools, and resources on HIV testing, prevention, treatment, and care.
According to the report, an increasing body of evidence shows that effective and cost-effective methods of prevention, screening and diagnosis of, and treatments for, common mental health conditions, including depression and anxiety, exist and can be implemented in low- and middle-income countries. Nevertheless, services for mental health, neurological, and substance use conditions are often not integrated into packages of essential services and care, including for HIV.
We know that integration of screening, diagnosis, treatment, and care for mental health conditions and psychosocial support with HIV services does not need to be expensive,” said Eamonn Murphy, UNAIDS Deputy Executive Director, a.i., Programme, as per the UNAIDS website.
The integrated approaches that are people-centered and local context-specific ensure better HIV and overall health outcomes, well-being, and quality of life.”Eamonn Murphy, UNAIDS Deputy Executive Director, a.i., Programme
While the focus of the publication is on the integration of mental health with HIV services and other interventions the considerations in the publication may be relevant to other services, including for HIV comorbidities such as tuberculosis, viral hepatitis, and sexually transmitted infections.
Mental, neurological and substance use conditions
Alcohol use conditions are highly prevalent around the world. In fact, they are the most prevalent substance use condition in general in the area of HIV/ AIDS.
- An estimated 283 million people are affected by alcohol use disorder.
- High-risk patterns of alcohol use increase risk of HIV infection.
- About 33,000 deaths (3.3%) of AIDS-related deaths were attributable to alcohol in 2016.
With this joint UNAIDS/WHO publication, we hope we can collectively support countries, service providers and other practitioners, policy-makers, program implementers, and communities in their efforts to address HIV, mental health, neurological, and substance use conditions for affected individuals in an integrated and impactful way,” said Devora Kestel, Director, Mental Health and Substance Use, WHO, as per the UNAIDS website.Devora Kestel, Director, Mental Health and Substance Use
The COVID-19 pandemic continues to have a serious impact globally on physical and mental health, including elevated distress, anxiety, depression, insomnia, and increased levels of alcohol and other drug use, and countries have reported disruptions to mental health, substance use and HIV services.
Individual-level and structural interventions are necessary to reduce barriers to access to HIV treatment and care, especially for key populations and other vulnerable groups, including adolescents, ageing and older people, and people with mental health, neurological and substance use conditions.
The unique HIV treatment needs of adolescents, pregnant women, key populations, people with advanced HIV disease, ageing and older people and people from other vulnerable groups are important factors to consider and address. People in these groups often face many negative social factors associated with poor mental health, increased risk of alcohol or other drug-related harm, loss to follow-up, and challenges with retention in HIV treatment.
The new guidance provides good practice opportunities for integration of services for mental health, neurological and substance use conditions into HIV service delivery.
On the individual and personal level:
- Integrate pre-exposure prophylaxis and voluntary medical male circumcision with screening for, and early identification of, mental health conditions, risk of suicide, drug use and dependence, and alcohol use disorder;
- Provide HIV post-test counselling, including assessment of mental health (including risk of suicide, depression, anxiety), drug use and alcohol use disorder, and referral for relevant services.
On the Health facility, community, government level:
- Increase community literacy on alcohol use and its relationship to HIV risk, adherence and metabolism of antiretroviral medicines for HIV treatment;
- Provide HIV testing services as part of individual assessment, and create community based and community-led treatment networks with HIV, services for mental health conditions, and support for people who use drugs or with alcohol use disorder in community settings.
In combination with HIV awareness campaigns, the wider community can be engaged in health promotion for mental health, neurological and substance use conditions, such as:
Ensuring people with mental health conditions, people who use drugs and people with alcohol use disorder, and their communities, play an active role in raising awareness and generating demand for services and support.
Prevention of substance use conditions
Preventive interventions can be delivered in primary health-care, HIV service delivery and community settings by training existing service providers.
Screening and brief intervention consists of one-to-one counselling sessions for adolescents or adults. It may include follow-up sessions or additional information to take home. The sessions can be delivered by a variety of trained health and social workers to people who might be at risk because of their alcohol or other drug use but who would not necessarily seek treatment.
Health-care providers should ask all pregnant women about their past and present use of alcohol and other drugs as early as possible in the pregnancy and at every antenatal care visit. Health-care providers should offer a brief intervention to all pregnant women using alcohol and/ or other drugs. Health-care providers managing pregnant or postpartum women who use drugs or with substance use disorders should offer comprehensive assessment and individualized care.
Family interventions to reduce alcohol use conditions include prenatal and infancy home visits by trained health workers to provide women with parenting skills and support with health, housing, employment and legal issues; and parenting skills programmes on positive development, prevention of child maltreatment and youth violence, and support management of behavioural problems in children and adolescents.
Other interventions for prevention of substance use conditions require policies or legislative responses. Interventions in the community may require linkages to education, social services and community networks.
Community-based prevention interventions to reduce use of drugs and substance use conditions include school-based interventions such as:
- Classroom environment improvement programmes.
- School policies on drug and alcohol use.
- Policies to retain children in school.
- School-wide programmes to enhance school attachment and belonging.
- Personal and social skills education for children and adolescents.
- Addressing individual psychological vulnerabilities.
- Early childhood education.
Other community interventions include:
- Emotional learning programmes to reduce adolescent risk for HIV and to prevent use of alcohol and drugs, self-harm and suicide.
- Skills training for service providers and caregivers.
- Psychosocial interventions with children for prevention of use of drugs and alcohol.
- Community interventions for suicide prevention.
Importantly, the guidance also highlights preventive interventions for neurological, mental health, and substance use conditions, that address alcohol harm specifically. These are:
- Reduce availability of alcohol,
- Increase taxation and pricing of alcohol,
- Ban promotion and advertising of alcohol,
- Label alcohol beverages,
- Enforce laws against driving under the influence of alcohol, and
- Strengthen health literacy on alcohol-related risks.
UNAIDS Press Center: “Key considerations to integrate HIV and mental health interventions”
UNAIDS document page: “Integration of mental health and HIV interventions — Key considerations“