By Raymond Castilleja Jr., LCSW, MBA, MHSM/ Behavioral Health Director at Prism Health North Texas
Tremendous biomedical advancements in HIV prevention and treatment have led to aspirational efforts to end the HIV epidemic. However, this goal will not be achieved without addressing the significant behavioral health conditions (mental health and substance use disorders) among people living with HIV (PLWH). PLWH can experience behavioral health issues that can affect quality of life, health care access, adherence to treatment and continuity of care.
Role of Co-Occurring Disorders & HIV
According to the Substance Abuse and Mental Health Services Administration (SAMHSA) and Health Resources and Services Administration (HRSA) Center for Integrated Health Solutions, PLWH have much higher rates of behavioral health disorders than the general population, specifically with:
Substance use and HIV/AIDS
- PLWH have high rates of past or current history of alcohol or substance use disorders.
- 66% have used illicit drugs and 16.5% have a history of intravenous drug use.
Mental Illness and HIV/AIDS
- Two to five times higher rates of depression.
- Higher rates of anxiety.
Trauma and HIV/AIDS
- A person who has experienced trauma and has a serious mental illness has an increased likelihood of being diagnosed with HIV.
- The prevalence of traumatic experiences among those with HIV can be as high as 42% for women and up to 70% for all PLWH – which means that people living with HIV are as much as twenty times more likely to have experienced trauma than the general population.
It’s important to recognize that behavioral health plays a vital role in the mission to end the HIV epidemic. Those at greatest vulnerability to and living with HIV come from a variety of lived experiences that can impact mental health status such as:
- Long-term effects of trauma
- May live with undiagnosed addiction
- Come from unsupportive family structures
- Live with suicidal thoughts on a regular basis
Integration of Care
The biopsychosocial complexity of HIV has resulted in efforts to integrate HIV-related mental health services with medical treatment as part of an overarching continuum of care. HRSA reports with the integration of behavioral health and primary care, patients receive high quality primary care with behavioral health services to help them cope with issues such as:
- Substance use disorders
- Problems resulting from living with a chronic physical health condition
In addition, the integration of services:
- Reduces stigma and discrimination
- Provides cost benefits
- Promotes improved client outcomes
Prism Health North Texas – Integrated Behavioral Health Program
The Prism Health North Texas (PHNTX) Integrated Behavioral Health Program (IBHP) supports HRSA in recognizing that primary care settings have become a gateway for many individuals with behavioral health and primary care needs. PHNTX found that integrating behavioral health services into primary care can better support the emotional, psychological, and social well-being of PLWH and help them achieve optimal HIV health outcomes. The behavioral health program implemented a strategy that offers a variety of care options from which clients are able to choose:
- Individual psychotherapy
- Group psychotherapy
- Psycho-education sessions
- Walk-in brief therapy
- Psychiatric evaluation
- Psychiatric medication management
- Crisis management, when needed
The stigma associated with having to retell their story when referred out for treatment is diminished because PHNTX provides services in-house. PHNTX integrated system creates a one-stop shop where clients can access in one visit their HIV medical care, mental health counseling, psychiatric care, case management, and other social services.
In 2018, 25% of PHNTX clinic population engaged in behavioral health treatment. Most importantly, significantly improved rates of viral suppression were achieved, meaning an increased percentage of clients with a level of HIV virus in the blood that is undetectable. Behavioral health clients achieved 83% viral load suppression compared to HIV care only clients at 86%. This is significant given that PLWH receiving behavioral health care are frequently facing complex challenges.
Importance of Integrated Care
Mental health impairments increase risk for HIV acquisition and for negative health outcomes among PLWH at each step in the HIV care continuum. Furthermore, when left untreated, mental illness and substance use can create additional health and psychosocial problems that go beyond non- adherence to HIV care. It’s clear that behavioral health care has the potential to impart significant, meaningful, and long-lasting impacts on people seeking and receiving HIV treatment. Integrated primary HIV and behavioral health care improves physical health outcomes and leads to increased savings in health care costs through reduced emergency room use, increased efficiency, reimbursable use of staff time and other means of cost-savings. The ability to integrate care in one location diminishes barriers to treatment and allows professions to provide collaborative care to achieve optimal health outcomes for PLWH.
-Remien, R.R. & Stirratt, M.J. (July 15, 2019). Mental health and HIV/AIDS the need for an integrated response. AIDS, volume number (33) Issue 9. Pp 1411-1420. Retrieved from https://journals.lww.com/aidsonline/Fulltext/2019/07150/Mental_health_and_HIV_AIDS__the_need_for_an.1.aspx#pdf-link
-Shah, V. (March 2018). Behavioral Health Integration within the HIV Continuum of Care. National Alliance of State and Territorial AIDS Directors. Retrieved September 19, 2019, from https://www.nastad.org/sites/default/files/resources/docs/issue_brief_final.pdf
-Farber, E. W. (2012). Integrating Behavioral Health with Medical Services: Lesson from HIV Care. Professional Psychology: Research and Practice. Vol. 43, No. 6, 650–657
-Health Resources and Services Administration (HRSA). (August 2019). HRSA Behavioral Health. Retrieved from https://www.hrsa.gov/behavioral-health
-The Case for Behavioral Health Screening in HIV Care Settings. (2016). Substance Abuse and Mental Health Services Administration and Health Resources and Services Administration. HHS Publication No. SMA-16-4999. Rockville, MD.
Raymond Castilleja Jr., LCSW, MBA, MHSM, is the Behavioral Health Director at Prism Health North Texas, in Dallas, TX. For 6 years, Raymond has worked as a psychotherapist practicing Cognitive Behavioral Therapy with people living with HIV/AIDS. Raymond is passionate about helping people with their mental health issues through integration of behavioral health into the primary care setting. Understanding his passion he pursued three master degrees (Master of Science in Social Work, Master of Business Administration, and Master of Health Systems Management) to be able to provide psychotherapy and business management in an organization. As director he is managing integration of behavioral health into the primary care setting.