Isa Fernández , Ph.D. Professor of Public Health and Preventive Medicine

1. Reauthorization Opportunities:Enhancing Mental Health and Substance Abuse Services in the Ryan White C.A.R.E. Act Isa Fernández, Ph.D. Professor of Public Health and Preventive Medicine Nova Southeastern University, Fort Lauderdale, FL On behalf of the American Psychological Association April 18, 2005

2. Why should mental health services and substance abuse treatment be maintained as core health services and their role expanded in the re-authorized C.A.R.E. Act?

3. Reasons • Prevalence of mental health and substance abuse disorders is much higher among PLWHA than in the general population. • If untreated, these disorders negatively impact individuals and society • individuals’ health and psychosocial outcomes • Increase health care cost and social burden • Mental health and substance abuse disorders are treatable.

4. Prevalence of Mental Health and Substance Abuse Disorders among PLWHA in U.S. • Almost half screened positive for mental disorders1 • Most common mental disorder is depression (62%) • Half screened positive for substance use/abuse (not marijuana)1 • Co-morbidity of mental health and substance abuse disorders is the norm, not the exception. 1Source: HIV Cost and Services Utilization Study

5. Comparison of Persons Screening Positive by Condition 1HCSUS: HIV Cost and Services Utilization Study 2NHSDA: National Household Survey on Drug Abuse

6. Adverse Impact of Mental Health and Substance Abuse Disorders • Impairs quality of life • Use of HIV related health services • Health outcomes (i.e., more compromised immune system; potential drug interactions) • Compromises adherence to medical regimens • May be associated with unsafe sex and illicit drug use increasing risk of HIV transmission • Increases health care costs • Increases economic and social burden

7. Mental Health and Substance Abuse Treatment Works • Improves adherence to antiretroviral medications • Improves utilization and retention in HIV medical care • Reduces the probability of interactions between illicit drugs and HIV medications • Improves quality of life (e.g. improved social relations, reduced homelessness etc.) • Reduces risk of transmission to others from unprotected sex and unsafe injection practices • Reduces economic and social burden of HIV on society (e.g., less health care costs, increased productivity etc.)

8. So what is the Problem? Despite the high prevalence and treatment advances, mental health and substance abuse needs of PLWHA are not being identified.

9. Why? • Clients self-perception of mental health needs is the most significant predictor of accessing care • People don’t want to be labeled as “crazy’ so they under report symptoms • In a recent study, less than half of PLWHA who had poor mental health functioning got treatment. “I could not put my family through another painful event…It would kill my mama…HIV was bad enough.. Now I had mental problems…I felt horrible all the time…Ms. Alfonso, she asked the right questions….getting treated for my depression changed my life”. 28 year old Hispanic woman, South Florida

10. Why? • Lack of training and expertise in assessing mental health and substance abuse needs. • Primary care physicians • Psychosocial service providers • Case managers • Screening for mental health and substance abuse problems is not standard practice in HIV care and services • Reliable and valid tools are available but not used • Inadequate resource allocations for services at the local level.

11. Recommendations

12. Maintain mental health and substance abuse treatment as core HIV-related health services. • Increase HIV Planning Councils and Consortia awareness of mental health and substance abuse needs of PLWHA • Encourage to designate higher priority and allocate a higher percentage of C.A.R.E. Act funds towards mental health and substance services

13. Mental health and substance abuse screening should be a routine component of all services supported by the C.A.R.E. Act. • Adequate recognition and treatment are central to improving the health and mental health outcomes of PLWHA

14. AIDS Education and Training Centers (AETC) should train all types of providers to screen for mental health and substance problems and to effectively and efficiently integrate these services as routine practice across all HIV related services.

15. Systematically collect standardized data to monitor and evaluate mental health and substance abuse services. • Need unduplicated, client-level service data which can better measure the impact of CARE Act services

16. HRSA should provide training and technical assistance to build local capacity to collect, analyze and interpret data on mental health and substance abuse screening and treatment.

17. The legislative language for the C.A.R.E. Act should utilize the more inclusive terms "health and mental health“ rather than “medical” when describing services.

18. Conclusions • Increasingly PLWHA are ethnic minorities, poor and uninsured. • Many are in need of mental health and/or substance abuse services. • As the payer of last resort, C.A.R.E. Act is the only vehicle through which many PLWHA can access needed services. • Take advantage of the reauthorization process to strengthen and expand much needed mental health and substance treatment for those at greatest need.