National Recommendations for Prioritizing Mental and Behavioral Health in Federal Implementation Efforts
The United States will become a place where new HIV infections are rare and when they do occur, every person, regardless of age, gender, race/ethnicity, sexual orientation, gender identity or socio-economic circumstance, will have unfettered access to high quality, life-extending care, free from stigma and discrimination.
Statement of Support
The American Psychological Association (APA) is the largest scientific and professional organization representing psychology in the United States and the world's largest association of psychologists. APA's membership includes 150,000 researchers, educators, clinicians, consultants, and students.
APA is committed to the development and implementation of national policies that support behavioral and social science HIV/AIDS research, science-based prevention interventions, and comprehensive mental and behavioral health service delivery in the context of HIV/AIDS prevention and care. APA believes that the National HIV/AIDS Strategy (NHAS) and its companion Federal Implementation Plan provide a long overdue roadmap to a comprehensive coordinated response to the domestic HIV epidemic.
Developed by APA’s Public Interest Government Relations Office, Office on AIDS and Committee on Psychology and AIDS, this document highlights the role psychology can play in achieving the NHAS’s three goals and the 2015 targets delineated in the Federal Implementation Plan. Inclusion of mental and behavioral health across all aspects of NHAS implementation is essential to help people protect themselves from HIV infection, to help those who are already infected from transmitting the virus to others, and to reduce adverse health consequences among those living with HIV. Congress, federal agencies, state, local and tribal governments, and non-governmental organizations can use this document to promote the incorporation of mental and behavioral health services into all aspects of HIV/AIDS prevention and care programs and policy development.
HIV continues to take a huge toll on individuals and communities, especially those that have the least access to early detection and treatment services. As our nation continues to wage the battle against HIV/AIDS, it is especially important to understand and address the emotional, attitudinal and behavioral factors that are critical to both HIV prevention and adherence to care.
-Norman B. Anderson, PhD, Chief Executive Officer, American Psychological Association
The American Psychological Association (APA) welcomed the release of the National HIV/AIDS Strategy (NHAS) on July 13, 2010, the first comprehensive national plan to address the domestic HIV/AIDS epidemic since the first cases of AIDS were identified three decades ago. The NHAS was developed by President Obama’s White House Office of National AIDS Policy (ONAP) with significant stakeholder input. APA supports the primary goals of the NHAS, which are to: 1) reduce HIV incidence; 2) increase access to care and optimize health outcomes; and 3) reduce HIV-related health disparities. The NHAS is expected to improve coordination across Federal agencies and at the state and local levels.
The Presidential Memorandum—Implementation of the National HIV/AIDS Strategy directs the head of each lead agency to submit a report to the ONAP and the Office of Management and Budget (OMB) on the agency's operational plans for implementing the NHAS within 150 days of the release of the strategy. We urge ONAP, OMB, the Department of Health and Human Services (HHS) and other federal agencies that will play a role in implementation to review the APA implementation priorities and to remain mindful of the importance of behavioral and social science research and practice in preventing HIV transmission, improving health outcomes, and eliminating HIV-related disparities for people living with HIV/AIDS.
More than 1.1 million Americans are living with HIV, and each year approximately 56,000 individuals become newly infected with HIV in the United States. The majority of these new infections occur among gay and bisexual men, African Americans, and Latinos. One-fourth of Americans living with HIV are women. HIV/AIDS disproportionately affects women of color, especially Black women who account for 80 percent of new HIV/AIDS diagnoses among women. APA supports national policies that target attention and resources to these most severely affected populations, along with strategies to make sure that all Americans know their HIV status and have access to quality medical and behavioral health care and support services if they need them.
Implementation of the NHAS must address gaps in HIV prevention, care, treatment and research for the most severely affected populations. For example, non-governmental organizations working on issues related to human rights, women and HIV/AIDS concluded that "to best serve women, sexual and reproductive health services must be integrated with all aspects of HIV care to meet the diverse needs of women and men, regardless of their HIV status. Program guidance and funding streams must concretely integrate sexual and reproductive health services with HIV testing, prevention and care” (Center for HIV Law and Policy, 2009).
Given that APA embraces the overall framework of the NHAS, we have chosen to prioritize mental and behavioral health issues for consideration as federal agencies develop their implementation plans and begin implementation. The rationale for a heightened emphasis on these issues is summarized below:
In a large, nationally representative probability sample of adults receiving care for HIV in the U.S., Bing and his colleagues (2001) found that nearly half of the sample screened positive for a mental disorder, nearly 40% reported using an illicit drug other than marijuana, and more than 12% screened positive for drug dependence. Further, more than one-third of the study sample screened positive for major depression. Research consistently demonstrates that sexual risk taking, mental health burden, and substance abuse are highly interrelated and reinforcing "epidemics" (Halkitis, 2010; Halkitis et al, 2011).
HIV seroprevalence rates ranging from 3% to 23% have been documented among persons living with a severe mental illness (SMI) (Weiser, Wolfe & Bangsberg, 2004). Epidemiological studies make clear that persons living with SMI are more likely to be victims of sexual coercion and intimate partner violence, live in risky environments, have unstable partnerships in high-risk sexual networks, use substances that impair decision-making, and lack the emotional stability, judgment, and interpersonal skills needed to avoid risk (Carey, Carey & Kalichman, 1997). Despite these many vulnerabilities, evidence suggests that even persons living with the most disabling mental disorders — including schizophrenia and other psychotic disorders — can reduce their risk of contracting HIV through group-level behavioral risk reduction interventions (see Carey, 2005 for a review).
Childhood sexual abuse, substance abuse, depression, and partner violence among gay men increase risky sexual behaviors both independently and through combined effects (Stall et al. 2003).
Mental health and substance use disorders have a negative impact on quality of life (Sherbourne et al, 2000) and are consistently associated with increased HIV risk behavior (Hutton et al., 2004; Booth et al., 1999), poor access to and engagement with health care, and poor adherence to antiretroviral treatment (Cook et al, 2002; Halkitis & Palamar, 2007; Halkitis, Palamar, & Pandey Mukherjee, 2008; Tucker et al, 2003; Mellins et al., 2009).
Neurocognitive impairments, although typically subtle or undetectable during the early phases of infection, can negatively affect adherence and self-care, especially among older individuals living with HIV (a critical issue given that the population living with HIV/AIDS is living longer), and among substance users who demonstrate poorer executive function and social cognition (Homer et al, 2008). Neurocognitive impairments have ramifications for health care, financial planning, and chronic care needs (Cherner et al., 2004; Cysique & Brew, 2009; Woods et al., 2008; Hardy & Vance, 2009; Lovejoy & Suhr, 2009).
Sexual risk-taking behaviors may be exacerbated by certain contexts, such as bars and clubs, sex environments, and the Internet (Halkitis & Parsons, 2002; Halkitis, 2010; Parsons & Halkitis, 2002; Pollock & Halkitis, 2009). Thus attention must be paid to the role that environments play in influencing behaviors and exacerbating mental health states that may predispose individuals to risk.
HIV disease affects individuals across all stages of life. There is an increasing number HIV-positive individuals aged 50 and over (GMHC, 2010) who are coping with the aging process while managing the physical, emotional, and social realities of HIV disease.
APA recognizes that the NHAS and the Federal Implementation Plan are cognizant of these findings. Our goal is to ensure that clear action steps are put in place through the remainder of 2010, 2011, and beyond to ensure that the NHAS results in the implementation of integrated approaches for HIV/AIDS prevention and care that include the provision of comprehensive mental health and substance use services across delivery systems.
APA developed its NHAS implementation priorities based on a review of the Federal Implementation Plan. The following eight priorities encompass areas where the unique perspectives of the field of psychology can make a significant impact in reaching the goals outlined in the NHAS within the timeframe of the Federal Implementation Plan—the remainder of 2010 and 2011. These priorities can inform the development of each lead agency’s operational plan for NHAS implementation. Our expertise can bolster the efforts of the Administration, Congress, state, local and tribal governments, and community stakeholders as they work together to implement the NHAS.
APA has identified the following priority areas for NHAS implementation:
Priority 1: Target resources to ensure that mental and behavioral health, neurocognitive, and substance use/abuse issues are systematically and comprehensively addressed in the context of HIV/AIDS prevention and care.
Priority 2: Target resources to increase screening for HIV in the context of mental health and substance abuse prevention and care service delivery systems.
Priority 3: Target resources to increase support for developing and evaluating behavioral and self-management interventions for people living with HIV/AIDS and other chronic diseases.
Priority 4: Increase funding for behavioral and social science research related to HIV/AIDS.
Priority 5: Expand technology transfer efforts associated with evidence-based approaches to HIV prevention by targeting resources for replication studies; intervention packaging and dissemination; training and capacity-building; and evaluation.
Priority 6: Invest in comprehensive school-based sexuality education for young people that includes HIV/Sexually Transmitted Infection (STI) education and risk reduction strategies designed and delivered in partnership with qualified locally identified and appropriate community-based organizations and providers.
Priority 7: Incorporate HIV/AIDS prevention and care strategies into the broader health care landscape and ensure that health and social service delivery systems are well equipped to take into account the dynamics of the domestic HIV epidemic and that appropriate resources are available.
Target resources to ensure that mental and behavioral health, neurocognitive, and substance use/abuse issues are systematically and comprehensively addressed in the context of HIV/AIDS prevention and care.
As described above, scientific research documents the importance of incorporating mental and behavioral health into HIV/AIDS prevention and care. Such a focus can provide support to individuals with co-occurring conditions and morbidities, such as substance-related and mental health disorders, interpersonal violence, sexual abuse, trauma, and homelessness, which may facilitate HIV transmission and compromise the effectiveness of standard HIV/AIDS care and treatment. However, these services usually do not receive sufficient attention or the requisite financial resources in HIV/AIDS prevention and care services.
Target resources to increase screening for HIV in the context of mental health and substance abuse prevention and care service delivery systems.
HIV screening is uncommon in settings where mental health and substance use/abuse services are provided, is not a high priority in these settings, and occurs haphazardly. The Federal Implementation Plan addresses this missed opportunity to identify HIV-positive individuals by including provisions to expand HIV screening in the Substance Abuse and Mental Health Services Administration (SAMHSA)-funded mental health and substance abuse prevention and treatment facilities (i.e., through consultation, development of guidance, and demonstration projects). These strategies should be coupled with efforts to enhance training and technical assistance for staff in integrating HIV testing and reaching high-risk individuals (i.e., men who have sex with men and high-risk heterosexuals). Further, efforts must be made to expand and implement best practices to integrate HIV counseling, testing, and referral services into mental and behavioral health and substance abuse program settings. Although the Federal Implementation Plan includes action steps that direct the Centers for Disease Control and Prevention (CDC), SAMHSA, and the Health Resources and Services Administration (HRSA) to explore strategies to increase HIV screening, additional resources will be needed to substantially scale-up expansion of HIV screening in mental and behavioral health and substance abuse settings once the exploratory work is complete.
Target resources to increase support for developing and evaluating behavioral and self-management interventions for people living with HIV/AIDS and other chronic diseases.
HIV/AIDS is widely recognized as a chronic illness within HIV care, but is often excluded from chronic disease lists outside the field. Similar to other chronic diseases, HIV requires life-long changes in physical health, psychological functioning, social relations, and adoption of disease-specific regimens. The shift from acute to chronic illness requires a self-management model in which patients assume an active and informed role in healthcare decision-making to change behaviors and social relations to optimize health and proactively address predictable challenges of chronic diseases generally and HIV specifically. Recognizing that self-management of HIV has more in common with all chronic diseases than differences suggests that the design and delivery of HIV support services can be incorporated into combined or integrative prevention and wellness services” (Swendeman, Ingram & Rothereram-Borus, 2009, p. 1321).
People living with HIV/AIDS can benefit from integrated care models to help them effectively manage their HIV disease and related conditions. Fragmented delivery systems often preclude these individuals from being able to access the full array of medical, mental and behavioral health, and social services and supports that they need. Goals 2 and 3 of the NHAS create an opportunity for research and testing of new HIV/AIDS care models to empower individuals with behavioral skills to be proactive in achieving optimal health outcomes.
Increase funding for behavioral and social science research related to HIV/AIDS in the following areas:
Service-delivery and service-utilization research that focuses on the identification of best practices for integrating mental health and substance abuse screening and brief treatment in the context of HIV/AIDS prevention and care;
Identification of standardized functions, common principles and practice elements across evidence-based prevention and care programs for the purpose of developing comprehensive and integrated intervention programs that have the potential for more cost-effectively addressing multiple health outcomes associated with chronic illness, including those associated with HIV/AIDS, at the same time;
Scientific support for delivery formats (Internet, cell phones, social networks, etc.), as well as research associated with the creation and evaluation of distribution platforms (wellness centers, minute clinics, cable health channels), for globally scaling evidence-based HIV prevention and care programs;
HIV prevention research that emphasizes the importance of developmental factors (e.g., how risk behavior, adherence, and coping change across the lifespan) and the interactive aspects of sexual and ethnic identities, with a particular emphasis on the risk associated with adolescence, emerging adulthood, and an aging HIV-positive population;
Structural-level HIV prevention and care research that focuses on couples, families, neighborhoods, and social contexts (sex environments, bars/cubs, the Internet) as the unit of intervention;
Behavioral and social science research that focuses on HIV prevention and care for Black men who have sex with men, including attention to the incidence of substance abuse and mental disorders. APA supports the Black Gay Research Group’s research agenda (BGRG, 2007), which articulates numerous priorities for research in relation to these three primary questions:
• What factors contribute to the high prevalence of HIV/AIDS among black men who have sex with men?
• What conceptual frameworks, research methodologies, and strategies and approaches will reduce the incidence of HIV/AIDS among this population?
• What factors promote and sustain the health and wellness of black men who have sex with men who are infected and affected by HIV/AIDS?
Behavioral and social science research that focuses on understanding disparities in HIV prevalence among Black women, including attention to the factors that facilitate HIV transmission, i.e., trauma and interpersonal violence, and interventions to prevent HIV infection and improve adherence to treatment regimens.
Expand technology transfer efforts associated with evidence-based approaches to HIV prevention by targeting resources for replication studies; intervention packaging and dissemination; training and capacity-building; and evaluation.
Over the years, the National Institutes of Health (NIH), Centers for Disease Control and Prevention (CDC), and other federal agencies have funded social and behavioral research that has yielded interventions that significantly reduce HIV-related risk behaviors, thereby reducing HIV infection risk. Although such research projects are valuable for the development of better social and behavioral prevention tools, their findings typically have been disseminated in a very select manner (e.g., peer reviewed articles) via very select mechanisms (e.g., clinical or academic journals and conferences) to a very select audience (e.g., other researchers). This strategy is effective in reaching mainly academic audiences, but it is ineffective in disseminating the methodologies and findings to those who need them the most: state-and local-level workers who are planning, developing, adapting, and implementing prevention activities in their communities” (Institute of Medicine, 2001, p. 68-69).
Although dissemination and technology transfer efforts have increased since the Institute of Medicine (IOM) report entitled No Time to Lose: Getting More from HIV Prevention was published in 2001 (largely as a result of the CDC Diffusion of Effective Behavioral Interventions (DEBI) program), substantially more funding is needed to build the capacity of community-based service providers and state and local health departments to adapt and implement science-based, community, group, and individual-level HIV prevention interventions. State and local health departments and directly-funded community-based organizations would benefit from increased guidance and flexibility in implementing promising interventions for populations where no DEBI intervention is available.
Invest in comprehensive school-based sexuality education for young people that includes HIV/Sexually Transmitted Infection (STI) education and risk reduction strategies designed and delivered in partnership with qualified locally identified and appropriate community-based organizations and providers.
One quarter of new HIV infections occur among adolescents and young adults aged 13-29. In the Federal Implementation Plan under Goal 1 “Reduce New Infection”, Step 3.2 “Promote age appropriate HIV and STI prevention education for all Americans” is an opportunity to bolster support for CDC’s Division of Adolescent and School Health’s (DASH) programs. These programs develop state and local education agency infrastructure in the areas of surveillance, program and curriculum, professional development, and collaboration with public health agencies. DASH’s network of funded non-governmental organizations can make significant contributions to these efforts. CDC’s implementation plan also provides an opportunity for developing action steps to foster partnerships between schools and community-based organizations to reach the youth at highest risk of infection (i.e., young men who have sex with men of color and young girls of color).
Incorporate HIV/AIDS prevention and care strategies into the broader health care landscape and ensure that health and social service delivery systems are well equipped to take into account the dynamics of the domestic HIV epidemic and that appropriate resources are available.
Enactment of the Patient Protection and Affordable Care Act provides a critical opportunity to ensure that our nation has the appropriate infrastructure to meet the mental and behavioral health needs of individuals across the lifespan. The new law includes provisions to foster integrated health care that includes mental and behavioral health; enhance prevention and wellness through investments in prevention and public health; improve access to mental and behavioral health care; and eliminate health disparities. These provisions can help the nation meet the NHAS’s goals if the Affordable Care Act is fully implemented and initial investments in health care reform made this year continue throughout the duration of NHAS implementation. In addition to greater access to health care, people living with HIV need a full range of social support services and access to stable housing to avoid becoming homeless. AIDS housing experts estimate that about half of people living with HIV/AIDS in the United States – over 500,000 households – will need some form of housing assistance during the course of their illness. Providing housing for poor people living with HIV/AIDS dramatically improves health outcomes and decreases risk behaviors. However, funding for housing for persons with AIDS remains woefully inadequate (NAHC, 2010). APA’s Report of the 2009 Presidential Task Force on Psychology’s Contribution to End Homelessness, which identifies and addresses psychosocial factors and conditions associated with homelessness and defines the role of psychologists in ending homelessness, is an important resource in this area.
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Leo Rennie, MPA
Telephone: (202) 682-5110