APA Public Interest Policy Office: April 2005

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HISTORY

The Ryan White CARE Act funds primary health and support services, including mental health and substance abuse services, for individuals with HIV/AIDS. The CARE Act is a payer of last resort, designed to fill the gaps left by private insurance, Medicare, Medicaid, and other publicly financed health care systems. CARE Act programs reach more than 500,000 individuals each year. The CARE Act was passed in 1990, reauthorized in 1996 and again in 2000 for a five-year period. The legislation is set to expire September 30, 2005.

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BACKGROUND

• Approximately 40,000 people are newly infected with HIV each year. Those at especially high risk include gay and bisexual men, women, racial/ethnic minorities, and injecting drug users and their sexual partners. An estimated 25 percent of new HIV infections each year is directly attributable to injection drug use. Individuals with a substance abuse problem or mental disorder are more likely to become infected with HIV than in the past, with the latter being almost one and a half times more likely to become infected than those without a mental disorder.

• Mental disorder and substance use or dependence are common among people with HIV. According to the nationally representative HIV Cost and Services Utilization Study (HCSUS), 50% of persons with HIV screened positive for illicit drug use, 36% for major depression, and 26% for a generalized anxiety disorder. By virtue of lower socioeconomic status, the prevalence of mental disorder is even greater among racial and ethnic minorities, who represent the majority of new HIV and AIDS cases.

• Persons with mental health or substance use problems frequently have difficultly managing their HIV. They tend to be less compliant with medication regimens and are less likely to utilize health services. This can lead to the emergence and potential transmission of drug-resistant HIV. Depression among persons with HIV has also been linked to a more compromised immune system and earlier mortality.

• According to a 2004 Institute of Medicine report (Public Financing and Delivery of HIV/AIDS Care: Securing the Legacy of Ryan White), mental health and substance abuse treatment can help stabilize the health and well-being of individuals with HIV and potentially improve adherence to antiretroviral drug treatment. According to HCSUS, 40% of persons with HIV received mental health services and 20% received substance abuse treatment. However, the rates are lower for persons of color, who have less access and lower utilization of mental health and substance abuse services than whites.

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RECOMMENDATIONS

1. Maintain mental health and substance abuse services as core health services in the Ryan White CARE Act. In 2002, the Ryan White CARE Act provided mental health treatment to over 80,000 persons, psychosocial support services to over 87,000, and substance abuse treatment, including outpatient care and residential treatment, to over 39,000. The median number of visits per year was 5.1 for mental health treatment, 7.8 for substance abuse residential services, and 6.1 for substance abuse outpatient services.
   
   
2. Utilize the more inclusive term "health and mental health" rather than "medical" when describing HIV/AID care and treatment to be consistent with the current language in the legislation. "Medical" treatment typically refers to services provided by those who are medically trained, such as a physician or nurse. However, psychologists provide essential health care services to persons with HIV and their formal training is not medically-based. To reflect the range of professional training that health care providers receive, it is advisable to use the more inclusive term "health and mental health" than "medical."
   
   
3. Further integrate mental health and substance abuse services into all HIV/AIDS care and treatment, including HIV counseling and testing. HIV-positive individuals who have co-occurring mental health and substance use disorders rarely receive "integrated" care with a treatment plan for all three disorders. Physical health, mental health, and substance abuse services are usually provided by different agencies. However, the HIV/AIDS Mental Health Services Demonstration Program found that HIV-positive individuals who received mental health or substance abuse treatment were more likely to receive and retain HIV primary medical care.
   
   
4. Incorporate mental health and substance use screening as a routine component of all services supported by the CARE Act. Primary care providers and case managers vary greatly in their ability to diagnose and treat HIV-positive patients with mental health or substance use problems. Depression is missed in 40% to 60% of patients in primary care. But mental health and substance use screening tools can improve providers' ability to address these needs, particularly if primary care and social service settings have limited professional mental health staff. Several diagnostic mental health and substance use screening tools are currently available for use by non-mental health staff.
   
   
5. Train providers in the HIV/AIDS Education and Training Centers (AETCs) on mental health and substance abuse screening and effective ways to integrate these services into the primary care setting. The program goal of the AETCs is to increase the number of health care providers who are educated and motivated to counsel, diagnose, treat, and medically manage individuals with HIV and to help prevent high-risk behaviors that lead to HIV transmission. Many health care providers have inadequate knowledge of the relationship between HIV/AIDS, mental health, and substance abuse and are unable to properly diagnose and treat HIV-positive patients with mental health or substance use problems.
   
   
6. Systematically collect standardized data to monitor and evaluate HIV-related services, including mental health and substance abuse services. Unduplicated, client-level service data provide the most accurate information on the number and demographics of people living with HIV/AIDS and can help service providers more accurately measure the impact of services funded by the Ryan White CARE Act. However, only four of 51 eligible metropolitan areas under Title I collect unduplicated data.
   
   
7. Require the Health Resources and Services Administration (HRSA) to provide training and technical assistance to build capacity to collect, analyze and interpret data on HIV-related services, including mental health and substance abuse screening and treatment. The CARE Act grantees are required to provide significant data to the HRSA/HIV Bureau, but many are not adequately trained or equipped in data collection and evaluation. Improving these skills can enhance the type of data collected and the evaluation process of Ryan White CARE Act services.

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