PEPFAR's Goals:

1. HIV/AIDS and Mental Health Integration: Is Something Not Right?Ilana Lapidos-Salaiz: MD, MPHTechnical Leadership and Research DivisionOffice of HIV/AIDS - USAID/Washington

2. ABOUT PEPFAR: Increase and build upon what works and, support countries as they work to improve the health of their own people: PEPFAR's Goals: • Transition from an emergency response to promotion of sustainable country programs. • Strengthen partner government capacity to lead the response to this epidemic and other health demands. • Expand prevention, care, and treatment in both concentrated and generalized epidemics. • Integrate and coordinate HIV/AIDS programs with broader global health and development programs to maximize impact on health systems. • Invest in innovation and operations research to evaluate impact, improve service delivery and maximize outcomes.

3. Evidence: Correlation between HIV and MH Impact of MH on HIV Impact of HIV on MH Mental health conditions in PLHIV are under-diagnosed and under-treated (WHO 2001) “PLWHA are twice as likely to suffer from depression than the general population (Ciesla & Roberts, 2001). “In all cohorts, ART was associated with reduced anxiety, depression, and dementia. In Cape Town, 85.5% of ART patients reported ‘‘no problems’’ with depression/anxiety after 12 months on ART, from 68.4% at baseline (Jelsma et al., 2005). • Mental illness may be a risk factor for HIV infection due to impaired judgment and high risk behaviors (Collins, et al. 2006; Smit el al. 2006) • Psychiatric disorders such as depression have been consistently linked with lowered likelihood of receiving HAART (Fairfield, et al, 1999)), • Results in poorer medication adherence (Ammassari et al., 2002; Catz, Kelly, & Bogart,2000) • if untreated, greater mortality” (Cook et al., 2004; Ickovics et al., 2001) • “For HIV-infected people, mental illness is a risk factor for non-adherence to antiretroviral therapy (ART) (Mellins et al., 2003). • Poor mental health undermines immune functioning and can negatively influence disease progression” (Antelman et al., 2007; Ickovics et al., 2001; Mellins et al., 2003; Murphy et al., 2004 • Successful treatment of depression improved adherence to ART(Dalessandro et al. 2007) and increases in CD4 counts(Horberg et al. 2008).

4. Continuum of care for PLHIV WHO continuum of care model proposes continuous and responsive support to PLHIV with input from different sources of formal and informal health care system… • Addressing Mental health* (and psychosocial support) is a key element of the continuum of care model - a comprehensive care approach that should be addressed at all levels of care • Advent of ART has resulted in PLHIV living “normal” active life but, • PLHIV experience range of emotional, social, and spiritual needs throughout their life

5. WHO pyramid Framework for optimal mix of services

6. Elements necessary for integrating MH services • Policy and guidelines • Incorporated into broader Public Health Strategy to achieve maximum coverage and commitment • Integrated into health care system – facility and community level • Referral systems/networks: Linkage between facility and care linked to community on-going treatment • Support for MH workers: • Human resource Development - Community/Primary care training in screening and delivery of MH services • Resources (including) funding • Drug supply and management (adapted from Kelly and Freeman, 2005

7. Realities on the ground… • Policymakers, donors, health care leaders are burdened with competing priorities • Goals targeting improved health must compete for policy attention and resources • Difficult for countries to commit adequate resources to comprehensively address mental health problems in that society, including PLHIV. • Countries/programs are at different stages of implementation – challenge for transition to more sustainable, country-led and owned programs • Program who are in less mature stages of system development are encouraged to learn from evidence base and use best practices to scale up services in efficient and effective manner

8. Gaps in MH services: Country profile of 9countries (2010): • Formulated mental health policy: 7 countries • Formulated substance Abuse policy: 6 countries • Formulated mental health program: 6 countries • Adequate policy funding 2 out of 9 countries • Access to services is varied: • Access to free essential medication (Psychotropic drugs): • Access to other basic services

9. Num b e r s o f c o u n tries r eporting na ti o n al g u idel i n es t ha t ad d r ess p r o vis io n o f p sy c h o l o gical/me nt al h e a lth se r vi c es ( N=2 5 ) Do n ’t kno w , 3 Y e s, s p e c ifi c f or N o , B O T H HI V - 8 i n f e c te d a n d g e n e r a l p o pul a t i o n , 3 Y e s, bu t n ot s p e c ifi c f or HI V - Y e s, s p e c ifi c f or i n f e c t e d ( g e ne r a l HIV - i n f e c te d , 5 p o pul a t i o n ), 6 Survey of 25 countries (2011):

10. Current USG efforts • Focused on increase screening and interventions in community and primary care setting • Integrate MH (depression and substance abuse) screening and treatment into HIV/AIDS (and other) services • Strengthen linkage between other care and support services and mental health care (depression and alcohol abuse) • Identify cost efficiencies and sustainable interventions

11. COP 2012: 36 countries reviewed

12. Acknowledgments • USAID and PEPFAR • Coordinating Organizations (U.S. Health and Human Services Office of Global affairs and U.S. National Institute of Mental) • Anne Herleth; Thomas Kresina (SAMHSA) For further information on the HIV/AIDS Care and Support work that USAID does under the Care and Support portfolio, refer to: http://www.usaid.gov/our_work/global_health/aids/TechAreas/caresupport/index.html. You may also refer to PEPFAR’s care and support page: http://www.pepfar.gov/strategy/prevention_care_treatment/133360.htm. For further information about presentation: ilapidossalaiz@usaid.gov