Download PL-1 All women All families

All Women, All Families:
Refreshing Our Vision for MCH
Families Impacted by HIV and the Interplay of
Mental Health
September 28, 2015
The findings and conclusions are those of the authors and do not necessarily represent the
official position of the Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, TB & STD Prevention
Division of HIV/AIDS Prevention
Elimination of Mother-to-Child HIV
Transmission (EMCT) Goal

Perinatal HIV incidence < 1 per 100,000 live births
 <40 cases among an annual cohort of 4 million births
AND

Transmission rate < 1%
 <87 cases (estimated 8,700 HIV-exposed births)
Summary of a Consultation on Perinatal HIV Transmission in the United States, 2008
Nesheim SR, et al. Pediatrics. 2012 Oct;130(4):738-44., Division of HIV/AIDS Prevention Strategic Plan
What do we know (estimate)?

HIV-infected women delivering infants annually
 ≈ 8700 in 20061
 ≈ 30% increase since 2000

HIV-infected children < 13 years old diagnosed per year
in 50 states (estimated)3
 223 (179 are perinatal) in 2009
 187 (107 are perinatal) in 2013
1Whitmore,
JAIDS 2011
AW et al. CROI 2012. Abstract T 103.
3CDC. HIV Surveillance Report, 2011; vol23.
2Taylor
What do we know (estimate)?

Mother-to-Child transmission rate:
 2-3%
 No significant difference in transmission rate by race/ethnicity,
(mirrors the tremendous racial disparity among women with HIV)
 ~85% mothers/infants Black, ~12% Hispanic, 2-4% white

Incidence of perinatally acquired HIV infection in the
United States5
Incidence
4CDC
Number
per 100,000
2008
268
6.8
2009
261
6.8
2010
212
5.7
HIV Surveillance Supplemental Report, EPS 2005-2008. 2011; vol 16 (2).
Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data—United States and 6
Dependent Areas—2011. 2013;18 (5)
5CDC.
HIV-infected women in care with ≥1 unplanned and no unplanned
pregnancies, by age at HIV diagnosis
Medical Monitoring Project, 2007 & 2008 (n = 382).
Sutton MY, Patel R, Frazier EL. JAIDS 2014 Mar 1;65(3):350-8
Perinatal HIV Prevention Cascade
Perinatal HIV Prevention Cascade
Pre-exposure
prophylaxis
Treatment as
Prevention (TasP)
New diagnostic
algorithm
Acute HIV infection
& repeat testing
Potential remission
with early treatment
infants
Framework to Eliminate Mother-to-Child HIV
Transmission in the United States
Nesheim SR, Taylor A, Lampe MA, et al. Pediatrics. 2012 Oct;130(4):738-44.
“When one tugs at a single thing in nature, (s)he
finds it attached to the rest of the world.”
-- John Muir
Syndemics
The concentration and deleterious interaction of two or
more diseases or other health conditions in a population,
especially as a consequence of social conditions that
promote disease clustering.
Merrill Singer, PhD, University of Connecticut
Syndemic Perspective


The multiple contemporary threats to the health of
marginalized and disadvantaged populations are not
concurrent epidemics in that they are not completely
separate phenomena
They constitute
 sets of enmeshed and mutually enhancing synergistic health
problems that, working together in a context of noxious social
and physical conditions, can significantly affect the overall
disease burden and access to services of a population
HIV/AIDS

Studying this history-changing disease and responding
to it within public health frameworks, as though it were
separate from other diseases is a distortion

As it exists in the world, HIV/AIDS is never separate from
other diseases,
 nor is it detached from social structures and social environments
 that channel the lived experiences and health and mental states
of infected individuals
Syndemics: HIV/AIDS

Research, prevention programs, policy interventions and
other aspects of public health practice have focused on
one disease at a time, leaving other health problems to
be addressed by parallel enterprises

Using the term epidemic to describe HIV/AIDS does not
adequately describe this serious public health problem
 Which involves the transmission of a virus in close conjunction
with a set of opportunistic diseases, but also with many nonopportunistic health conditions.
Syndemics

We need to assess the nature of the specific
interconnections and pathways of influence among
the parts,
 Including the intricate ways in which they foster and reinforce
each other and
 Thereby create complex, burdensome and challenging webs of
entwined health and social problems
Mental Illness

26.2 % of Americans ages 18 and
older suffer from a diagnosable
mental illness in a given year.

About 6% suffer from a serious
mental illness.

Mental disorders are the leading
cause of disability in the U.S. and
Canada.

Many people suffer from more
than 1 mental disorder at a time
(45%).
http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml
Mental Illness and HIV
 The direct effects of HIV on the brain
 Stigma and distress associated with having HIV infection
or being a member of a marginalized group
 As manifestations of the opportunistic infections and
diseases associated with HIV
 As a result of medications used to treat HIV infection and
its complications
Reference documents at www.psych.org/aids and www.hivguidelines.org
Common Mental Health Problems Among
HIV+ People
 Mood disorders
 Anxiety disorders
 Stress disorders (PTSD)
 Alcohol/substance use disorders
 Psychotic illnesses
 Somatic problems: insomnia, pain, fatigue, sexual
dysfunction, reactions to body habitus changes
 Neurocognitive disorders due to opportunistic
Reference documents at www.psych.org/aids and www.hivguidelines.org
HIV Continuum of Care: Total Population,
United States
Mental Illnesses Can Impact Each Step
of the Continuum of HIV Care

Among mental illnesses, alcohol and other substance
use disorders and depression have been consistently
associated with a reduced likelihood of being engaged in
care.

IAPAC expert panel recommended that, to enhance
entry into and retention in HIV care, we should treat
substance abuse, depression and other mental illnesses.
IAPAC= International Association of Providers of AIDS Care
Studies Linking Poor Mental Health with
Difficulties Engaging in HIV Care

Study of delayed HIV diagnosis found multiple life
stressors (six were studied including substance use
issues past 12 months and history of hospitalization for
mental illness) were associated with delayed HIV
diagnosis*

Antiretroviral Treatment Access Study (ARTAS): A
linkage to HIV care intervention was effective among
people without depressive symptoms, but not effective
among those with depressive symptoms**
*Nelson KM, et al. AIDS Education and Prevention, 2014
**Gardner LI et al. AIDS Patient Care STDs. 2009.
Severe Mental Illness

People with Severe Mental Illness are at increased risk for
infections with HIV, hepatitis B and C.
 Estimated 8-fold incidence of HIV than standard US population rate
 Estimated 5-fold incidence of hepatitis B
 Estimated 11-fold incidence of hepatitis C
Rosenberg SD et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness.
Am J Public Health 2001; 91: 31-7
HIV Infection and Mental Illness

The populations we seek to reach in preventing and treating
HIV infection have a much higher prevalence of mental
illness (including substance use disorders) than the general
population.

Mental illnesses are associated with acquiring HIV,
transmitting HIV, delayed HIV testing, difficulties engaging in
HIV care and treatment, and death from HIV infection.

HIV prevention and treatment outcomes would be
considerably enhanced through addressing mental illness.
Rosenberg SD et al. Prevalence of HIV, hepatitis B, and hepatitis C in people with severe mental illness.
Am J Public Health 2001; 91: 31-7
Mental Health & Substance Abuse:
Recommendations from the EMCT
Stakeholders Group

Mental health and substance use issues:
 Weak linkages between HIV and MH/SA services
 Unavailable, inaccessible, and/or compartmentalized MH/SA
services impact the ability to provide comprehensive HIV
healthcare
 Workforce policy/training issues impede the provision of effective
MH/SA service
 Lack of access to reproductive health increases the overall
burden on women, which can impact mental health
Common Recommendations and Example Actions from
FIMR/HIV projects
Trauma-Informed Care: An Approach to Improve
Engagement of Women Living with HIV
Webinar
Thursday, November 12th, 2015
Noon-1:30 pm ET
To Register: http://tinyurl.com/p6kymjc
Case Review & Community Action: Uncovering
and Addressing Mental Health Issues Among
Women
Skills Builder Session “B”
Tuesday, September 29th
2:30pm-4:00pm
4:15pm-5:45pm (repeat)