Cross-sectional data from the Brazilian National Unified Health System’s medical and health databases were used to assess adherence to antiretroviral therapy (ART) in people with HIV and comorbid, moderate or severe psychiatric disorders, including substance use, in medical care from January 2014 to December 2018, in the large Brazilian city of Campo Grande. Compared to the general population of people with HIV, those with comorbid mental health disorders were significantly less likely to adhere to antiretroviral therapy. In this study, only 16% of the sample met criteria for HIV medication adherence. Other risk factors for ART non-adherence included lack of follow-up medical visits, older age, and unstable housing.
Strengths and limitations:
The study’s principal strength is its use of large, medical, infectious disease, and psychiatric databases that include inhabitants of a large metropolitan area. This government-sponsored system is more likely to capture subpopulations of underserved, marginalized people living with HIV and mental health disorders. However, stigma associated with HIV, mental health and substance use disorders may be a barrier to care and thus findings may underestimate the problem. Other limitations include lack of generalizability of findings to other countries and other regions in Brazil, and use of medication dispensing history and self-report as proxies for medication adherence. The study’s descriptive and cross-sectional design precludes assumptions about causation.
The greater than expected co-occurrence of psychiatric morbidity in people with HIV and its negative effect on morbidity and mortality are well-documented. This study provides additional support to the important role that mental health clinicians play in ending HIV. Treatment as prevention and HIV pre-exposure prophylaxis are two pillars of the US national strategy to stop HIV transmission. Access, uptake, and adherence to these biomedical interventions are essential to their effectiveness. This study also reminds us that systems-level interventions, such as integration of mental health and substance use services with HIV medical care, are an important aspect of effective HIV care delivery.
PUBLICATION #2 — HIV Psychiatry
NEJM, Perspective Investing in National HIV PrEP Preparedness.
Jeremiah Johnson, Amy Killelea, Kenyon Farrow.
Abstract: N Engl J Med. 2023 Mar 2;388(9):769-771. doi: 10.1056/NEJMp2216100. Epub 2023 Feb 25.
This NEJM Perspective is a call for Congress and the Biden Administration to create a national program that insures access to HIV preexposure prophylaxis for all Americans, especially vulnerable and marginalized communities. Despite remarkable advances in HIV medicine that have dramatically reduced morbidity and mortality, HIV incident rates remain unacceptably high. Communities of color account for disproportionately high numbers of new infections and disproportionately low rates of PrEP uptake. Ending HIV will take political will and commitment of resources at federal, state and local levels targeting the uninsured and underinsured. Pharmaceutical companies, laboratories, and pharmacies working in coordinated fashion with provider networks and non-clinical community-based organizations will be required to reach these vulnerable populations. Building this infrastructure for HIV would prepare for future public health emergencies and could already be applied to monkeypox and HCV.
PUBLICATION #3 — HIV Psychiatry
High Virologic Suppression Rates on Long-Acting ART in a Safety-Net Clinical Population .
Abstract: Presentation #518.
This abstract, presented at the 2023 Conference on Retroviruses and Opportunistic Infections, described an NIAID- and NIMH-funded study that assessed the use of long-acting antiretroviral treatment (LA-ART) in historically underserved people with HIV (PWH); those with mental illness, substance use disorders and unstable housing. PWH experiencing these conditions have limited access to care and face significant barriers to ART adherence. They have been left behind in the remarkable progress made in treating HIV. In addition, this disadvantaged group is less likely to receive LA-ART since the FDA approved it for PWH who have already achieved viral suppression on oral ART. The study included 133 participants with unstable housing or homelessness, mental illness, or substance use disorders. At baseline, 57 participants were either not virologically suppressed or untreated and 76 were suppressed. At follow-up, all 76 suppressed participants remained virologically suppressed, and, 55 of the 57 (97%) unsuppressed participants had achieved viral suppression. Previous studies demonstrated that patients treated early with uninterrupted ART have better outcomes and are significantly less likely to transmit HIV to their partners. This study addresses existing unequal access to treatment and improved outcomes among PWH with co-existing psychiatric and substance-related morbidity and psychosocial vulnerabilities.