About 1.1 million people in the United States have been diagnosed with HIV, and each year about 39,000 more learn that they have the virus. Meanwhile, fewer than half of those living with HIV have the virus under control, according to the Centers for Disease Control and Prevention (CDC), and only about 15% of those at high risk for contracting HIV are being treated with pre-exposure prophylaxis (PrEP), a drug that protects against the virus.
In his 2019 State of the Union address, President Donald J. Trump announced an ambitious new goal: to stop the HIV epidemic in the United States by 2030. By focusing on “hot spots” of new infections—48 U.S. counties, seven rural states and two cities—the administration aims to reduce new infections by 75% over the next five years and by 90% over the next decade. In October, the Department of Health and Human Services (HHS) through the CDC awarded $13.5 million in its first round of fundingopens in new window to local and state departments of health, and the fiscal year 2020 HHS budget will include $291 million in new funding to address the HIV epidemic.
However, how all of that money will be used is still an open question. The Substance Abuse and Mental Health Services Administration (SAMHSA), for instance, did not receive additional funding in the president’s plan to address the epidemic, and some experts are concerned that this omission reflects a largely biomedical approach from the Trump administration, when a behavioral approach may be equally important.
“We were really glad that [HIV] became a topic again,” says Monica Ulibarri, PhD, chair of APA’s Committee on Psychology and AIDS (COPA) and associate program director in the California School of Professional Psychology’s clinical psychology PhD program in San Diego. But, she says, addressing issues such as mental health and substance use is “half the battle” in ending the HIV epidemic. “If you have the medications but you don’t bring people to them, you can’t use those tools.”
Barriers to care
The administration’s plan has four prongs: prevent new cases of HIV through prescribing PrEP to those at high risk, diagnose all of those with the virus, treat them with anti-retroviral therapy medications and respond rapidly to emerging hot spots of new infection. The last aspect is key because many new cases of HIV in the United States are found in close-knit communities and geographic regions, such as the 2011–14 outbreak in Scott County, Indiana, where the virus quickly spread among people sharing drug-injection equipment.
Officials say the plan will allow counties, states and districts receiving federal funds to decide where to allocate funding—so if Scott County, for instance, decides that substance use counseling would help curb the epidemic among those who use drugs, local officials could put some of the funds toward counseling. But because behavioral health is not explicitly part of the plan or mentioned in its four main areas of focus, some experts worry that officials implementing the plan across the country may not realize that psychosocial resources are necessary or even permissible under the federal funding. And while the plan does target geographic hot spots, it is less successful at prioritizing the specific communities in those areas that are the hardest to reach with health care, says psychologist Jennifer Brown, PhD, an associate professor of psychiatry at the University of Cincinnati College of Medicine and a COPA member. “Oftentimes those are the communities at greatest risk for acquiring [and] spreading HIV.”
Indeed, U.S. HIV infection rates are growing most rapidly in the communities that face significant challenges in accessing health care, including among Latinx people, African Americans, American Indians and Alaska Natives, men who have sex with men, transgender people, sex workers and people who inject drugs. And the region of the country where HIV infection rates are increasing fastest is the South, especially the rural areas. Only about 37% of Americans live in the South, but the region sees more than half of all new HIV infections in the United States.
Without addressing the tangled web of issues that make tackling the HIV epidemic in these communities so challenging, some psychologists say, ending the epidemic isn’t possible. Those issues include stigma, discrimination, racism, homophobia and transphobia, as well as the ways in which those biases interact with existing health barriers like poverty, lack of health insurance and a paucity of providers. Many patients have difficulty adhering to medication regimens, which is complicated by social issues such as unsteady income, unstable housing and food insecurity, as well as cultural insensitivity or lack of knowledge on the part of some providers. And many people at risk for or living with HIV also have co-morbid conditions, such as exposure to trauma and violence, substance use disorders and mental health issues.
These aren’t just complications to overcoming the epidemic, says clinical psychologist Robert Remien, PhD, director of the HIV Center for Clinical and Behavioral Studies at Columbia University, which is funded by the National Institute of Mental Health. “These are drivers of the HIV epidemic.”
Interventions that work
Psychologists are uniquely qualified to help address many of these barriers, says Remien, who was on a New York state governor’s task force to develop a plan to end the HIV epidemic in the state. They can help by identifying those who may be living with HIV or more likely to acquire HIV, offering them HIV counseling and helping them stay in care. They also have a deep understanding of how certain experiences and behaviors—including exposure to trauma and violence, substance use disorders and mental health issues—drive risk by leading to risky sexual behaviors or injection drug use.
The administration’s plan aims to stop the HIV epidemic by prescribing anti-retroviral medication to people with HIV and PrEP to those at high risk of acquiring it.
“There’s a real emphasis right now on biomedical strategies, whether that’s PrEP for prevention or getting individuals living with HIV onto anti-retroviral medications,” Brown says. But psychologists understand that reaching people who need the medications and getting them to take the pills regularly are enormous challenges that have more to do with behavior than anything else.
In one study of men who have sex with men, for example, she and her co-authors found that among participants living with HIV, stigma often led to depression—and that depression diminished patients’ ability to adhere to their medication regimens (Mitzel, L.D., AIDS and Behavior, Vol. 19, No. 8, 2015). The study concluded that effective HIV adherence programs need to include treatment for depressive symptoms.
Treatment for mental health and substance use disorders is important for prevention as well as treatment adherence. In Ohio, where Brown lives, the HIV epidemic has shifted toward individuals who use opioids and other drugs, she says. In an analysis of randomized controlled trials with more than 1,300 total participants, she and her colleagues found that addiction treatment was often associated with decreased risky sexual behaviors, such as those that could lead to HIV (Prevention Science, Vol. 19, No. 6, 2018).
Iván Balánopens in new window , PhD, a clinical psychologist and research scientist at the HIV Center for Clinical and Behavioral Studies at Columbia University and a COPA member, studies sexual risk behavior among men who have sex with men, among other topics. He stressed the importance of listening to patients and working with them toward their goals. For instance, providers who offer PrEP may be eager to get at-risk patients on medication as quickly as possible—but if patients aren’t ready to take it, they won’t. “Just because we as providers are ready for someone to begin on PrEP doesn’t mean that they are ready to do so,” Balán says. Instead, providers need to engage with such patients—a field in which psychologists often have experience they can share, he says. Balán recommends “ motivational interviewingopens in new window ,” a patient-centered counseling approach with demonstrated efficacy in facilitating behavior change, including improving treatment adherence. Instead of asking, for example, why patients didn’t take their medication on a certain day, Balán will ask them what helped them take it on the days they were successful—thus helping the patients solve problems and set goals.
“If their goals are to remain HIV negative or their goals are to achieve undetectable viral loads, you align yourself with those goals,” he says. “Because if we impose something on them and they’re not ready, then they fail and the next time just becomes so much harder.” Balán and other researchers found that providers who used motivational interviewing while staying attentive to their community’s views of antidepressants helped Latinx patients stay on medications for depression (Lewis-Fernández, R., Psychiatry: Interpersonal and Biological Processesopens in new window , Vol. 76, No. 3, 2013) as well as stay in behavioral therapy programs ( Cognitive and Behavioral Practice opens in new window, Vol. 23, No. 2, 2016).
On the basis of such research, psychologists recommend integrating mental health care and substance use treatment more fully into the Trump administration plan. For example, the Ryan White HIV/AIDS Program is a safety net program offering supportive services, including mental health care and substance use treatment, that help patients adhere to HIV treatment plans—and 86% of patients enrolled in the program have the virus under control.
“Those kinds of services and programs work, but those are not available to everyone,” Remien says—including patients on PrEP. “There’s not an equivalent of the wraparound services if you’re not living with HIV.”
Jessica Sales, PhD, associate professor of behavioral sciences and health education at Emory University in Atlanta, says that addressing social and psychological factors is crucial to ending the epidemic. Without supporting patients’ psychological and socioeconomic well-being, she says, “we will likely still be in a similar place.”
Psychologists and other researchers also emphasize the need to change federal policies to reach marginalized people. That includes addressing cuts and limits to Medicaid, the Affordable Care Act and other programs that provide reproductive health services, harm reduction, safe housing, food assistance, disability benefits and more. And laws and court decisions removing legal protections for sexual and gender minority individuals and other marginalized groups mean that those who are at risk for HIV or who have tested positive for the virus may not feel comfortable accessing needed services for fear of being refused services or facing discrimination.
“Some of the rhetoric that’s happening in this country around sexual orientation and gender identity is not helping these efforts,” Remien says. “Battles over bathroom rights or all that stuff…. It’s rhetoric, but it’s also the policies that are coming from that rhetoric—that are working against our goal of ending the HIV epidemic.”
