Mental health and HIV

Poor mental health can contribute to HIV risk and affect outcomes of HIV care, and living with HIV or risk of HIV can contribute to poor mental health. Editor-in-chief of The Lancet HIV, Peter Hayward, joins Gavin and Jessamy to discuss new research on the overlapping issues and where the opportunities for improving care can be found.

Read the Series papers here:
Alignment of Mental Health and HIV Services

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Gavin: Hello, welcome to the Lancet Voice. It's June 2022, I'm Gavin Cleaver, and I'm here as ever with my co host Jessamy Bagginall. We're talking today about HIV and mental ill health as conditions that can exacerbate each other. Poor mental health can contribute to HIV risk and affect care outcomes, and living with HIV, or the risk of HIV, can contribute to poor mental health.

A new series of papers in three Lancet journals, that's the Lancet HIV, the Lancet Child and Adolescent Health, and the Lancet Psychiatry, examine different aspects of the interplay between these two conditions among different key populations. To find out more about these populations, about intersectionality, mental health and HIV, and how integrating mental health into HIV services can have very positive outcomes, I spoke to Editor in Chief of the Lancet HIV.

Peter Heywood. If after this you'd like to read the papers, you can find them on thelancet. com And I've also put the link to the papers in the show notes, so you can just click through as well So here's me and Jessamy talking to Peter Heywood.

All right, so Peter Heywood editor in chief of the Lancet HIV Thanks so much for joining us to talk about the new series in collaboration with two other Lancet journals The Lancet Child Nurse and Health and the Lancet Psychiatry Tell us a little bit about this series, how it came about, where the idea came from.

Yeah 

Peter: thanks for having me on to talk about the series. The idea for the series really came about last year and I thought I'd really like to work with the Lancet Psychiatry, mental health and HIV. Two fields that are really linked, but we haven't done that much about in the past.

We've had a couple of bits of research, but I really thought it'd be great to explore the possibility of working with the Lancet Psychiatry, as I say. So I started talking with with the editor, Niall there about the possibility, and we came up with the idea of Looking at how to came up with the idea of doing a series that would look at how HIV and mental health services could be aligned and could, to benefit the populations affected.

And to do that, our initial idea was to have two papers looking at specific populations and their populations affected by HIV and their mental health needs. So we were going to do a paper on substance users that would be published in the Lancet Psychiatry and a paper on adolescents that would be published in the Lancet HIV.

But when I started investigating the adolescence paper and who might write that, I kept finding myself looking at resources in the Lancet Child and Adolescent Health. So then I thought, oh let's see if they want to get involved as well. So approached the editor of the Lancet Child and Adolescent Health, Jane, to see if she would like to get involved.

And yeah, she did. And so then we expanded the series to include three populations adolescents, substance users, and the men who have sex with men. And these are all three populations that bear a particular disproportionate burden of HIV and have specific mental health needs. We limited it to three papers because although there are other populations that would be very interesting to cover, if we'd expanded it to more papers than that, we'd have inevitably ended up repeating some of the messages and the overlap would have been too great.

Gavin: It's interesting that you talk about, your kind of desire to work with the Lancet Psychiatry and how there wasn't a huge amount of overlap between published works between Lancet Psychiatry, because I feel like that's a kind of key of the series, this kind of lack of alignment.

Between HIV services and mental health services. 

Peter: Yeah, it's something that is, it's recognized. We haven't invented some new fields here. There's a lot of people who do work on this. But there really is, there is a need for better alignment. There's certainly so much more that could be achieved by people thinking about this a bit more and thinking about the opportunities that healthcare contacts, whether they're mental health contacts or contacts to support people with their HIV, how actually bringing in thinking about mental health or bringing in HIV across the two fields could really help to improve the care and help to get people the right services that they need, whether there's mental health services for people living with HIV, or HIV services for people who have mental health problems.

Gavin: So there is a kind of I saw in the series as well, there's a disproportionate burden of of HIV among people who have mental health issues. 

Peter: It's a huge, it's a complex interaction going on there and it varies for different populations how these things work, but broadly having mental health issues can increase your risk of HIV.

It can also if you're living with HIV, having mental health problems can can limit your ability to manage the disease. For example, you might not access the HIV care that you need. You might be on treatments, but you might have trouble at being adherent to the treatment, which then means you have, you suffer ill effects from your HIV, from HIV infection.

Jessamy: Yeah, I was interested to see it framed as a syndemic this sort of interaction between mental health and HIV. And I wondered whether you could just unpack it a bit for us and describe what that really means. And. how it happens. 

Peter: Yeah, absolutely. So it's particularly in the paper on many how sex with men where they go into the idea of mental health and HIV being a syndemic.

Now, syndemic theory is the idea that two or more conditions co occur. At high prevalence and interact with each other in a way that reinforces that co occurrence and synergistically affects the outcomes of those conditions, so for men who have sex with men as I mentioned previously mental health can contribute to hiv risk and make people more prone to adverse hiv outcomes but then living with hiv Or being at risk of hiv can impose a mental health burden on people So you've really got these two things reinforcing each other.

And then for many have sex with men. On top of that interaction between mental ill health and HIV burden. There's also other pressures related to, stigma, discrimination, marginalisation. In some cases criminalisation of sex. Their lifestyles and identities. And it's not just limited to men who have sex with men.

I think, you can view it as a sen as HIV and mental ill health as a syndemic for other populations as well. 

Jessamy: I think that's right, isn't it? And there's all this, there's a real intersectionality about it, where people who, are from marginalized community are impacted and affected even more.

And, the comments they look at, pregnant adolescents, people experiencing homelessness, and female sex workers. It's complicated, those different contexts, but I suppose there must be a sort of overriding or, common themes throughout. 

Peter: Yeah, absolutely. The point about intersectionality is so important.

There is, I think each of the papers highlights and the comments that we have as well, they all highlight the many sort of layers and factors that contribute to the interactions between HIV and mental ill health. And it's really complicated and each population is different, but what is common is that there are this intersectionality.

All these different factors that contribute to this for example, adolescents have particular mental health needs in relation to HIV, but then if a young woman, adolescent girl or young woman becomes pregnant that introduces a whole other range of issues. Sex workers might have specific needs, but then trans sex workers have those needs but then others as well and for some of the most marginalized people, sex workers, homeless people, etc.

Considering appropriate interventions is really important, but actually just getting care contact might be the first major hurdle for people facing barriers imposed. But that's why it's so important to think about the co occurrence of HIV and mental health and why if services can be aligned in some way Any health contact can then be optimized and this becomes particularly important I think in resource limited settings where donor organizations fund HIV care but actually psychiatric care is really lacking so I think there's an opportunity a real opportunity there.

Jessamy: Hey Anne, I wonder if we could just dig into this sort of adolescent issue because there's a whole paper on adolescent Adolescents and HIV, with HIV and their sort of particular risk of mental health issues. Maybe you could just expand on that a bit for us and think about take us through some of the different reasons that, that happens and what it means.

And I suppose also how it relates into some of our other work in terms of adolescence being this very important time in people's life for health in terms of setting up healthy behaviors. Amazing. Lifestyle for the rest of their adult lives. 

Peter: Yeah, so just before I start on, before I answer the question, I just wanted to point out that the vast majority of adolescents with HIV are in sub Saharan Africa.

Yeah. And the mental health problems that affect adolescents really encompass internalizing and externalizing disorders, mood disorders, emotional distress, cognitive disability, and substance misuse. And as as the authors of the the book, paper in the series Lucy Kluver and Lorraine Sherratt and colleagues point out.

Studies show that one in four adolescents living with HIV meets criteria for having a psychiatric condition. And that's huge. And that's, as I say, predominantly based in sub Saharan Africa. The reasons behind mental ill health amongst adolescents can vary, obviously for all. Those adolescents who were infected vertically, so they've had HIV since birth, there can be a biological impact of the virus and the infection and treatment that might lead to psychiatric illness.

But then all adolescents, because as you rightly say, adolescence is such a pivotal time for people's health, living with HIV can really have impacts related to their interactions with people around them, for example. Adolescents living with HIV might experience bullying and other stigma. Also adolescents, because of the historic high burden of HIV and the impact that's had in sub Saharan Africa, often adolescents living with HIV might have lost family members which can contribute to mentally ill health.

And also There's a high burden of abuse experienced by adolescents living with HIV from their carers and family. So all of this really, can contribute to a high burden of mental health amongst adolescents. And actually on top of that, it's worth mentioning that over the past two years the COVID pandemic has been particularly hard on, on young people and particularly challenging for them with concerns about schooling and isolation and so on.

And so that also contributes to this burden amongst that population. 

Gavin: Yeah, it's really interesting that you mentioned stigmatization there because of course we can think of this in one way as you know The kind of mental burden of having to deal with kind of a lifetime condition But also stigmatization and bullying must play a huge part in this as well.

Peter: Yeah. Yeah, stigma and bullying for adolescents and but yeah, stigma and discrimination is a huge issue. I think for all these populations, particularly for adolescents but as I mentioned, substance users may be excluded, excluded because of the legal environments and also in many places, with high burdens of HIV, there are still laws that criminalize criminalize same sex behavior as well.

Stigma is one of the biggest issues and is something that needs to be tackled in, it's a real barrier for, barrier to care for many of the populations we consider. And it's really one of the things that first needs to be addressed to be able to make the most of any service alignments and this sort of cooperation.

Can 

Jessamy: I just ask a question about this? And there's not going to be a right answer, but it's just something that you always feel a bit concerned about when you listen to these stories and you pathologize the mental health aspect, but actually their response is a trauma, presumably, the trauma of.

being diagnosed with HIV early of being, having stigma, of being abused, all of these other risk factors that they have. Is there a risk in pathologizing? this as mental health. Obviously we need to provide them, the services and support that they need, but do you know what I mean?

It's almost like this is a natural response to having a really difficult condition as an adolescent. 

Peter: Yeah, absolutely, I agree. And I think, someone better versed in mental health might have a better take on it, for me. But no, absolutely. I think, a lot of, I think one of the things that the papers do mention, the adolescent paper particularly, is that actually, A lot of mental health, a lot of the opportunity for mental health in this situation is stuff that can you know, interventions or support that can help to halt a developing mental health issue or prevent mental health issues developing.

So if you can build into, HIV care contacts, appropriate signposting for services or networks or support groups that can, help adolescents come to terms with. an HIV diagnosis and the other factors in their life that might contribute to mental ill health, you could actually, stop a more serious mental health problem developing.

And I think that's one of the things that the paper does highlight. 

Gavin: It often feels like the capacity for mental health services is quite limited to people going through the more acute episodes of mental health issues. Is accessibility a major issue when we're talking about people with HIV accessing mental health services?

And of course, you mentioned as well the difficulty to reach populations, the stigmatization that might stop people coming forward. Those sort of issues must be tied in with it as well. 

Peter: Yeah, absolutely. Stigma and discrimination are, as I mentioned, huge barriers to care for some populations. If your identity or behavior is criminalized, you may be very reticent to seek support for that or even seek, you might be concerned that an HIV diagnosis will reveal to people that, or, People might assume from an HIV diagnosis that you that, you belong to a population that's stigmatized and so you might be reticent to seek care.

But also, on a, more, on a more basic level, in resource limited settings, mental health provision is seriously lacking. One of the things that's really been a great benefit to HIV is international financial support for HIV programs And there's you know HIV programs have developed a lot of health Infrastructure in some quite in sort of some resource limited settings So really there's potential to make a big difference through integration of alignments integration of or alignment of HIV and mental health services.

At the bare minimum just training people who are providing HIV care through donor supported systems to be aware of the signs of mental ill health. And as I said previously, to signpost to signpost to appropriate support could be a great first step. Yeah, in in resource limited settings, community and peer support can be a great help for people experiencing emotional distress and helping people entering HIV care to make links to peer support and community networks.

My might help to halt the development of or to prevent mental health issues, as I said previously. So we think the papers also make a really strong case for for HIV programs to include funding and support for mental health services and that's, whether the programs are funded nationally or by international donor organizations.

Gavin: So what does this kind of better integration? look you talked about it in resource limited settings there, but for instance in the UK, what could be done better? 

Peter: Yeah, I think 

Gavin: in the 

Peter: first instance it really just required training people in base specialties to be aware of the potential of co occurrence of HIV and mental ill health.

And also then to, training them to provide appropriate signposting and appropriate care where possible. There's also a case for much closer integration there's a couple of examples in the paper on substance users. These examples from Spain, so that services addressing the psychiatric need of, substance misuse.

They have HIV care embedded in them so they'll have, as well as the psychiatric and psychology, psychological care, they'll have an infectious diseases specialist who can test for HIV or who can and other other illnesses, but also people accessing these services could be initiated on treatment if needed, or receive adherence counseling if that's something they're struggling with.

And now of course there's no, there's no blueprint for this and there's not one size fits all. I think The papers highlight that there's, while there are good examples of things dotted about and stuff could, there's lots of things to be learned from, there's also not a great evidence base to support these sorts of interventions.

But also, each population, each setting is so different in terms of healthcare needs and healthcare capacity. That although there are common factors and common sort of common ideas that under would underpin this integration or alignment Really does need to be tailored locally and to the population being considered A mental health care in particular really needs to be adapted to local context But as I say, I think these HIV programs to mentor to recognize mental health needs 

Gavin: So in summary, it's better to add mental health services to systems that already exist to reach these populations rather than a more generalized mental health for people with HIV service.

Peter: Yeah, I think, yes, I think so. I think it's not don't need to reinvent the wheel. It's just about making sure that that the appropriate services are available for the populations that need them. And there is an opportunity to do that where there are existing HIV services, but also actually.

Particularly in resource limited settings, as I mentioned, there's HIV services exist and you add mental health in there, but actually In in better resource settings or settings with stronger mental health infrastructure, training people within that to recognize signs of HIV risk or to, or ways to approach, bring HIV management into mental health services just because there is this co occurrence of these two two conditions and people could really benefit from people in both specialties thinking about the other.

Gavin: I wanted to finish up by talking a little more generally. Editor in chief of the Lancet HIV. You see all the cutting edge research about HIV coming through. What's the current state of HIV treatment? Sometimes you hear rumblings about vaccines. Obviously PrEP has been a bit of a game changer recently.

Yeah, what's the kind of state of play at the moment? 

Peter: It's a really encouraging situation, I think. Think of about 38 million people estimated to be living with HIV worldwide, 28 million people are on treatment. And that's, that's incredible. Almost, impossible to imagine, over a decade ago or whatever.

I think it's, yeah, in 2010, fewer than 8 million people worldwide were receiving treatment. That's a huge change. What's been the kind of driver behind that change over the last 10 years? Access to affordable medications systems to provide, drugs at an affordable price to low resource settings where, that have the highest burden of HIV.

This, the health system set up to, to treat people with HIV and just a really concerted effort. It, it's recognition that, there isn't a vaccine, there isn't a cure, the way to stop people The way to save lives of people living with HIV is to treat them and also treatment blocks transmission if someone is on treatment and their virus is suppressed.

They cannot pass on HIV. So getting people on treatment is one of the most effective ways to prevent HIV. And, over the course of the past 10 15 years drugs have improved they have fewer side effects, they're simpler to take, so you can You know, instead of a huge pill burden daily now for a lot of people it's just one or two, one or two pills a day to control HIV.

And yeah it's. A really great success story. Now there are still still a lot of people living with HIV who aren't on treatment and that needs to be addressed. That's a matter of finding those people, diagnosing those people. And that's again about, access to care, access to diagnostics.

But yeah, it's a really positive thing. And as you say, you mentioned PrEP, which is having which is having a great impact on people who don't have HIV, taking a pill a day or, managing, managing sort of their prep use around periods of potential risk of HIV exposure. Yeah, that's making a huge difference in helping to bring down numbers of new infections.

Yeah, it's a really, it's a really great story. And there's also there are. vaccines that people are trialing and there's interest in using mRNA vaccines after the experience of COVID and seeing what, seeing whether there's any possibility there. But HIV is still proving somewhat intractable to vaccines.

And we've had some recent disappointments in vaccine, in a vaccine trial. But on the treatment side, Also, there's now long acting injectable treatments, which means you can give people an injection once every month, once every eight weeks and that's enough to keep the virus suppressed.

Now, some people might prefer a daily pill to the injections or whatever, but it's great to have diversifying options in terms of treatment, a range of different drugs, a range of different routines of taking drugs, so that people can really find, find the treatment that suits them.

And that's the same for prevention as well with there's PrEP, but there's also, You can use the long acting injectable drugs as PrEP as well. So some people might stick to daily pill taking, some people might get the injections. There's the microbicidal rings, which are which can help women to manage their HIV risk.

So these diverse options, it's really encouraging. And yeah, no, I think it's quite a positive, HIV treatment and prevention. 

Gavin: Do you think I guess you've been editor in chief of Lancet HIV for a good few years now, do you, would you have been happy with this point? If you someone had said to you in 2022, this is what the HIV outlook.

Would look like. Would you have been, that's a positive kind of success story or? I think it's 

Peter: a sort of, it's a trajectory one might have been able to predict in a way. I don't think there's there was, when Lancet was already this great commitment. Drugs were becoming more accessible shortly after we launched.

Policy was changed to, instead of waiting for people's CD4 count to drop to a certain level before you start treatment, recognizing that treatment is effective. is really effective as prevention. Shortly after the Lancet HIV launched, the global recommendation for instant treatment upon diagnosis of HIV came in.

So I think it's a great situation, as I said, it's a real success story, slightly predictable. It's such a great story. It would be great if there had been, in the time, in the period that the journal's been going, a cure or a vaccine, a real sort of game changer like that. But there hasn't been.

But, the situation we're in now is really testimony to the hard work of people all over the world. doing the groundwork, getting people diagnosed, getting people on treatment, and really maximizing the diversification in treatment, new modalities, and diversification in prevention as well.

Fantastic. 

Gavin: Thanks so much Pete. This has been fantastic. I've really enjoyed it. It's really good to have this kind of overview of HIV as well as talk about, the mental health aspects of the series. And hopefully we can drive a few people to read the series as well.

Peter: Yeah, I would really encourage everyone to that. It's a three great series papers Really thought provoking and hopefully, you know inspiring some meaningful change So thank you very much for giving me the chance to speak to you about them

Gavin: That's it for this episode of the Lancet voice if you want to carry on the conversation You can find Jessamy and I on Twitter on our handles at Gavin Cleaver and at Jessamy Bagonal You can subscribe to the Lancet voice if you're not already wherever you usually get your podcasts and if you're a specialist in a particular field Why not check out our In Conversation With series of podcasts, tied to each of the Lancet specialty journals, where we look in depth at one new article per month.

Thanks so much for listening, and we'll see you again next time.