The findings and conclusions are those of the authors and do not necessarily represent the official...

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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 All Women, All Families: Refreshing Our Vision for MCH Families Impacted by HIV and the Interplay of Mental Health September 28, 2015 National Center for HIV/AIDS, Viral Hepatitis, TB & STD Prevention Division of HIV/AIDS Prevention

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Transcript of The findings and conclusions are those of the authors and do not necessarily represent the official...

Page 1: 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.

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

All Women, All Families: Refreshing Our Vision for MCH

Families Impacted by HIV and the Interplay of Mental Health

September 28, 2015

National Center for HIV/AIDS, Viral Hepatitis, TB & STD PreventionDivision of HIV/AIDS Prevention

Page 2: 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.

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, 2008Nesheim SR, et al. Pediatrics. 2012 Oct;130(4):738-44., Division of HIV/AIDS Prevention Strategic Plan

Page 3: 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.

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 20112Taylor AW et al. CROI 2012. Abstract T 103.3CDC. HIV Surveillance Report, 2011; vol23.

Page 4: 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.

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

4CDC HIV Surveillance Supplemental Report, EPS 2005-2008. 2011; vol 16 (2).5CDC. Monitoring Selected National HIV Prevention and Care Objectives by Using HIV Surveillance Data—United

States and 6 Dependent Areas—2011. 2013;18 (5)

NumberIncidence

per 100,000

2008 268 6.8

2009 261 6.8

2010 212 5.7

Page 5: 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.

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

Page 6: 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.

Perinatal HIV Prevention Cascade

Page 7: 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.

Perinatal HIV Prevention Cascade

New diagnostic algorithm

Potential remission with early treatment infants

Acute HIV infection & repeat testing

Pre-exposure prophylaxis

Treatment as Prevention (TasP)

Page 8: 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.

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.

Page 9: 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.

“When one tugs at a single thing in nature, (s)he finds it attached to the rest of the

world.”-- John Muir

Page 10: 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.

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

Page 11: 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.

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

Page 12: 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.

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

Page 13: 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.

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 non-opportunistic health conditions.

Page 14: 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.

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

Page 15: 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.

Mental Illness

http://www.nimh.nih.gov/health/publications/the-numbers-count-mental-disorders-in-america/index.shtml

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%).

Page 16: 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.

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

http://www.psych.org/aids
http://www.hivguidelines.org/
Page 17: 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.

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

http://www.psych.org/aids
http://www.hivguidelines.org/
Page 18: 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.

HIV Continuum of Care: Total Population, United States

Page 19: 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.

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

Page 20: 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.

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.

Page 21: 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.

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

Page 22: 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.

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

Page 23: 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.

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

Page 24: 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.

Common Recommendations and Example Actions from FIMR/HIV projects

Page 25: 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.

Trauma-Informed Care:  An Approach to Improve Engagement of Women Living with

HIV   Webinar 

Thursday, November 12th, 2015Noon-1:30 pm ET

To Register: http://tinyurl.com/p6kymjc

Page 26: 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.

Case Review & Community Action: Uncovering and Addressing Mental

Health Issues Among Women

Skills Builder Session “B”Tuesday, September 29th

2:30pm-4:00pm4:15pm-5:45pm (repeat)


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