Integrating Behavioral Health in HIV Clinics

1. Session # C2b • October 17, 2014 Integrating Behavioral Health Consultation Services into HIV Clinics Bryce Carter, Ph.D., Clinical Director of the Project and Behavioral Health Consultant, Hospital of the University of Pennsylvania; Victor Lidz, Ph.D., Professor, Drexel University Medical College Department of Psychiatry and Project Director; • Collaborative Family Healthcare Association 16th Annual Conference • October 16-18, 2014 Washington, DC U.S.A.

2. Faculty Disclosure • We have not had any relevant financial relationships during the past 12 months.

3. Learning ObjectivesAt the conclusion of this session, the participant will be able to: • List the ways in which the Behavioral Health Consultation Model might be adapted to work within an HIV care clinic or other specialty care clinics. • Identify the ways in which a knowledge of the HIV/AIDS epidemic aids in building trust and rapport with both patients and medical providers. • Discuss the behavioral health needs of populations of patients in HIV primary care as compared with FQHCs

4. Bibliography / Reference • Cohen, M.A., Barista, S.M., & Lux, J.Z. (2010). Settings and models of AIDS psychiatric care. In M.A. Cohen, H.W. Goforth, J.Z. Lux, S.M. Barista, S. Khalife, K.L. Cozza, & J. Soffer (Eds.) Handbook of AIDS Psychiatry (pp. 3-33). Oxford University Press, New York. • Cruess DG, Kalichman SC, Amaral C, Swetzes C, Cherry C, et al. (2012). Benefits of adherence to psychotropic medications on depressive symptoms and antiretroviral medication adherence among men and women living with HIV/AIDS. Annals of Behavioral Med 43: 189–197. • Farber EW, Bhaju J, Campos PE, Hodari KE, Motley VJ et al. (2010). Psychological well-being in persons receiving HIV-related mental health services: the role of personal meaning in a stress and coping model. General Hospital Psychiatry 32: 73-79 • Heaton, R.K., Franklin, D.R., Ellis, R.J., McCuthan, J.A., Letendre, S.L., LeBlanc, S., Corkran, S.H., Duarte, N.A., Clifford, D.B., Woods, S.P., Collier, A.C., Marra, C.M., Morgello, S., Mindt, M.R., Yaylor, M.J., Marcotte, T.D., Atkinson, J.H., Wolfson, T., Gaiman, B.B., McArthur, J.C., Simpson, D.M., Abramson, I., Gamst, A., Fennema-Notestine, C., Jernigan, T.L., Wong, J., Grant, I. (2011). HIV-associated neurocognitive disorders before and during the era of combination antiretroviral therapy: Differences in rates, nature, and predictors. Journal of Neurovirology 17 (1): 3-16. • Hult JR, Wrubel J, Bränström R, Acree M, Moskowitz JT (2012). Disclosure and nondisclosure among people newly diagnosed with HIV: An analysis from a stress and coping perspective. AIDS Patient Care STDs 26: 181-190 • Kaaya S, Eustache E, Lapidos-Salaiz I, Musisi S, Psaros C, (2013). Grand Challenges: Improving HIV treatment outcomes by integrating interventions for co-morbid mental illness. PLoS Medicine 10 (5): e1001447. doi:10.1371/journal.pmed.1001447 • Khalife, S., Scoffer, J., & Cohen, M. A. (2010). Stigma of HIV and AIDS – psychiatric aspects. In M. A. Cohen, et. al (Eds.) Handbook of AIDS Psychiatry (pp.89-104). Oxford University Press. • Moskowitz JT, Wrubel J, Hult JR, Maurer S, Acree M (2013). Illness appraisals and depression in the first year after HIV diagnosis. PLoS One 8 (10): e78904. doi:10.1371/journal.pone.0078904

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. SAMHSA Funded Project • Part of Twelve Cities Inter-Agency Program • Concentrating services for HIV+ patients in cities with largest numbers of patients • Funded in part by all three SAMHSA Centers • Grant awarded to Philadelphia Department of Public Health, AIDS Activities Coordinating Office • Collaboration of Department of Psychiatry, Drexel College of Medicine, Mental Health Association of Southeastern Pennsylvania, and Health Federation of Philadelphia • And six HIV care clinics in the city

7. Project Elements • AIDS Activities Coordinating Office • Overall planning, direction, and coordination • Drexel Department of Psychiatry • Hiring and supervision of behavioral health consultants (BHCs) • Mental Health Association • Hiring of Recovery Coaches/Peer Specialists • Health Federation • Expertise, training, and advocacy for BHC model

8. Participating Clinics • Partnership Comprehensive Care Practice, Drexel College of Medicine • MacGregor Clinic, University of Pennsylvania Medical Center • Infectious Disease Clinic, Penn Presbyterian Medical Center • HIV Comprehensive Care Clinic, Temple University Medical Center • Immunodeficiency Clinic, Albert Einstein Medical Center • Ambulatory Health Centers, Philadelphia Department of Public Health (four clinics)

9. The BHC Model • Consultation on patient “behavioral health” needs with medical providers as requested • Brief, focused visits with patients • Typically in medical examination rooms • 15-20 minute sessions in cycle with medical providers • Typically 1 to 4 sessions per patient • Focused progress notes in the medical record or EMR • “Low threshold” access to behavioral health care • Eschewing the “therapist” model • Interventions for a wide variety of needs • Depression, anxiety, trauma, substance abuse, smoking cessation, support for exercise, good diet, etc. • Help with medication adherence, disclosure of HIV+ status to various others, prevention of HIV transmission, etc.

10. Hiring the BHCs • Reviewed around 240 applications • Interviewed about 40 qualified candidates • Outstanding two or three candidates for each clinic also interviewed at the clinic • Hiring dependent on approval at clinic • Six hired BHCs included four clinical social workers (two still accumulating hours for LCSW) and two PhDs in Clinical Psychology • All had prior experience working with HIV+ patients • One had been trainee at her assigned clinic

11. Training the BHCs • Studied two textbooks on the BHC model in primary care • Shadowed BHCs practicing at FQHCs under the Health Federation umbrella • Specific trainings by outside consultants of Health Federation • Including shadowing of BHCs during start-up • Training in writing progress notes for medical record • Orientations to BHC model for HIV care clinics by supervising BHC from clinic affiliated with Health Federation • Joint coordination meetings with the Recovery Coaches to encourage linkages • On-going monthly group sessions at Health Federation • Bi-weekly “team meetings” convened at Drexel Outpatient Psychiatry

12. Starting the BHC Services • The several BHCs started between May and August, 2012 • Start-up orientation held at each clinic for all clinic staff • Introducing the BHC • Introducing the BHC model of care • Health Federation consultant visited, shadowed, and advised the BHCs • Repeated discussion of start-up issues in team meetings • Clinical Director (Dr. Carter) later visited the clinics of the consultants out-of-state to view their procedures and patient flows

13. Start-Up and Routinization • Referrals from medical providers were initially slow at all clinics • Rates of referrals increased at different rates at the various clinics • Variables affecting referral/engagement rates: • Clinic size • Number of nurse practitioners • Number of other non-physician clinicians (pharmacists, case managers, etc.) • Whether physicians defined their roles as primary care or as infectious disease specialty care

14. A Recent Monthly Report

15. Project-to-Date Data

16. Some Interpretations • The BHCs have achieved very high rates of penetration of their clinics • In FQHCs, 25% penetration is viewed as strong and showing effectiveness of the service • The BHCs have higher numbers of repeat visits with patients than BHCs at FQHCs • Some patients have 10 or more visits • Due to complexity of needs • Due to challenges keeping them from engaging in formal therapy • The high penetration rates relate to the complex behavioral health needs of the patients

17. Prominence of Support for Medical Treatment • Although BHCs also engage patients for classical behavioral health issues (depression, anxiety, trauma, relationship difficulties), a major focus of their care is on supporting patients in engaging in medical treatment: • Attendance at appointments with medical providers • Adherence to medications • Regularity in attendance and adherence • Modifying conduct to prevent transmission of HIV • Disclosing HIV status to appropriate others • And not disclosing when perhaps inappropriate • Disclosure – esp. to partners and family - often relates to treatment engagement

18. The HIV Virus

19. Some History • The first cases of what would later become known as AIDS were reported in the United States in June of 1981. Over 1.8 million people in the U.S. are estimated to have been infected with HIV, including over 650,000 who have already died; today, more than 1.1 million people are living with HIV. • While the number of new HIV infections is down from its peak in the 1980s, new infections have remained at about 50,000 for more than a decade.

20. AIDS Memorial Quilt displayed on the National Mall, October 1987

21. The Current Picture • Rapid testing for HIV testing is now much more available yet 16% of those infected with HIV remain undiagnosed and many people with HIV (32%) are diagnosed late in their illness. • Treatment advances have substantially reduced AIDS-related morbidity and mortality and extended the lives of many. • Current U.S. HIV treatment guidelines recommend initiating antiretroviral therapy (ART) as soon as one is diagnosed with HIV.  

22. The Current Picture Cont. • Many people with HIV are not in care, on treatment, or virally suppressed – the point at which the virus is under control and a person can remain healthy and reduce the risk of transmission. • HIV-related mortality rates rose through the 1980s and peaked in 1995, ha declined significantly; the age-adjusted HIV death rate has dropped by 85% since its peak. • In 2010, HIV was the 7th leading cause of death for those ages 25-44, down from #1 in 1994 and 1995.

23. HIV Continuum of Care

24. A Bit More History and Context • Racial and ethnic minorities have been disproportionately affected by HIV/AIDS since the beginning of the epidemic, and represent the majority of new HIV infections, people living with HIV disease, and deaths among people with HIV. • The first effective therapy against HIV (AZT) was approved by the FDA in 1987. Subsequently other medications were developed but even in combination were unable to adequately suppress the virus and patients still inevitably died. • In 1996 a 3 drug therapy known as Highly Active Anti-Retroviral Therapy (HAART) was incorporated into clinical practice and rapidly showed impressive results with a 60% to 80% decline in rates of AIDS, death, and hospitalization. • Pre-exposure prophylaxis, or PrEP, is a way for people who do not have HIV but who are at substantial risk of getting it to prevent HIV infection by taking a pill every day. When someone is exposed to HIV through sex or injection drug use, Prep reduces the risk of infection up to 92% when taken consistently. Often recommended for sero-discordant couples,

25. HIV Medications There are six classes of anti-retroviral drugs aimed at preventing replication of HIV at various points of the life cycle: Careful monitoring of drug-drug interactions and side effects are necessary

26. Adherence • Adherence can be inadequate despite both provider and patient understanding of the consequences of nonadherence. • Successful long-term treatment of HIV/AIDS requires at least 95% adherence to HAART in order to prevent emergence of drug-resistant HIV variants that lead to regimen failure and limit options for future therapy. • Despite the prevalence of inadequate adherence, many patients succeed, and HAART has transformed HIV infection into a chronic illness rather than a death sentence.

27. Adherence Cont. • The barriers to adherence observed in HIV treatment resemble barriers to the successful treatment of other chronic diseases: regimen complexity, side effects resulting in poor tolerability, patient lifestyle factors, and patient-provider relationships. • Treatment of HIV infection has shown that patient-provider collaboration can result in the selection of a lifestyle-tailored regimen characterized by convenient dosing, low pill burden, and tolerable side effects that enhances adherence, effectiveness, and the patient's willingness to remain on anti-HIV therapy long term.

28. More on Adherence • Adherence to medication is a key aspect of HIV management • 95% or higher levels of adherence are necessary for viral suppression. • Counseling can help patients identify barriers to adherence and helping patients to adopt a problem solving approach has been shown to be an effective intervention. • Barriers specific to HIV care center on fears around disclosure and external stigma (patients don’t want to take their pills in front of other people) . • Internal stigma – taking their medication reminds them ofHIV status.

29. Understanding the history and controversies surrounding the HIV/AIDS epidemic is essential to building trust with clinic patients and providers many of whom have lived through the early years of the epidemic

30. The disease was initially thought to be limited to MSM and IV drug users which served to increase feelings of stigma in the general population, medical professionals, and those infected • Heightened stigma lead many in the past (and present) to avoid getting tested or treated for fear of rejection and discrimination • The slow response to the epidemic by the medical profession, government, press and pharmaceutical companies lead to public reaction including the Names Project/The AIDS Quilt • ACT UP – AIDS Coalition To Unleash Power – a direct action organization worked draw attention to the epidemic and to bring about changes in legislation, medical research and treatment policies.

31. ACT UP Philadelphia

32. Multiple Losses • Many long term survivors have lost many friends and loved ones and may be suffering from grief and/or survivor’s guilt.

33. Provider Expectations of Care • Medical providers often have long term relationships with their patients and have sometimes brought them back from the brink of death and they want to be very sure that BHCs and other professionals provide a very high level of care. • Important to avoid the perception of a “meet and the street” level of care.

34. HIV Stigma • HIV stigma refers to the HIV related shame, fear, prejudice and discrimination. • Sociologist Erving Goffman described stigma as the inability to manage your own, now spoiled, identity. • Patients may refer to themselves as “toxic”, “tainted”, and “unwanted”.

35. Dealing with Stigma and Disclosure is an everyday experience for those living with HIV

36. Stigma Continued • Comprehensive research on the health impact of HIV stigma has yet to be performed, however anecdotal evidence links it to lower rates of HIV testing/diagnosis, lack of engagement in care, lower rates of adherence, depression, impaired relationships, and social isolation. • How to treat stigma? Again, little research has been done in this area , some studies have shown that exposure to positive role models is effective. Other approaches include education, empowerment, helping the person to change their personal narrative from that of spoiled identity to that of a wounded but courageousindividual.

37. Adjustment to HIV Diagnosis • A complex issue and a number of considerations must be assessed: • Stage of HIV illness at the time of diagnosis. • Patients diagnosed with advanced stage disease are often hospitalized with a life threatening opportunistic illness,. • Some have exposed their partners to HIV. • Patient’s partner and family sometimes learn of a previously undisclosed of sexual behavior or drug use. • Early stage disease adjustment focuses on education, importance of medication adherence, engagement in care, risk of transmission, treating comorbid psychiatric issues, partner notification, and connection with other support services.

38. Adjustment to HIV Continued • Early stage disease adjustment focuses on: • Health education, • Importance of medication adherence, • Engagement in care, • Risk of transmission, • Addressing comorbid psychiatric and other health issues, • Partner notification, and • Connection with other support services.

39. Psychiatric Aspects of HIV • Individuals living with HIV are disproportionately affected by psychiatric illness. • Prevalence estimates of psychiatric disorders among HIV-infected individuals have varied widely owing to differing study designs, methods of diagnostic assessment and the populations studied. • The Coping with HIV/AIDS in the Southeast (CHASE) study, a cohort study of 611 HIV-infected persons receiving care in southeastern USA,[2] and the National HIV Costs and Services Utilization Study (HCSUS), a comprehensive national survey of HIV-infected individuals, suggest that as many as 48–54% of HIV-infected individuals are likely to have a psychiatric disorder. • Mental illness in HIV-infected individuals is associated with a lower likelihood of receiving antiretroviral medications, adhering to prescriptions and with high HIV risk behaviors, and raise obvious concerns in caring for HIV-infected persons.

40. Psychiatric Aspects Cont. • The Coping with HIV/AIDS in the Southeast (CHASE) study, a cohort study of 611 HIV-infected persons receiving care in southeastern USA, and the National HIV Costs and Services Utilization Study (HCSUS), a comprehensive national survey of HIV-infected individuals, suggest that as many as 48–54% of HIV-infected individuals are likely to have a psychiatric disorder. • Mental illness in HIV-infected individuals is associated with a lower likelihood of receiving antiretroviral medications, adhering to prescriptions and with high HIV risk behaviors, and raise obvious concerns in caring for HIV-infected persons.

41. Depression • Depression and HIV – considerations include: • Did the depressive illness predate HIV diagnosis and • If so, how did the HIV diagnosis impact the depression: • How much of the depressive illness is influence by stigma? • The social isolation so common in depression in the context of HIV may actually represent the individual’s efforts to cope with stigma (I don’t want to infect anyone else), and/or represent a response to internal or external stigma (I don’t go around those people cause they know I am positive, I can see how they look at me). • Proper assessment requires teasing out the different elements of depression and stigma and in order for interventions to be effective they must target both the depressive symptoms andthe effects of stigma.

42. Suicidality *HIV + status can exacerbate and complicate a suicidal concerns because HIV isoften considered a death sentence even after the patient has received counseling about HAART. *Stigma can play a role in exacerbating suicidal feelings (it would be better for everyone if I was not here).

43. Anxiety, Neurocognitive Disorders, & Bipolar Illness Anxiety – HIV + status and associated stigma exacerbates social anxiety and fears of rejection. For those patients who have experienced life threatening illness the anxiety can be reflected in concerns about their CD4 count, viral load, and concern over other physical ailments. HIV associated Neurocognitive Disorders (HAND) prevalence rates are between 10 and 24% and are associated with low CD 4 counts and high viral loads. Because moderate to severe levels of HAND can impact memory special attention must be paid to adherence. BHCs have helped play a role in early detection and screening for HAND. Bipolar illness requires special consideration in the context of HIV and regular psychiatric care is essential to effective symptom management. Both ends of the bipolar spectrum can influence decisions about adherence, medical care, and risk behaviors. BHCs can play a role in regular monitoring of mood symptoms and provide MI to promote reengagement in specialty psychiatric care, as well as screening for possible hospitalization.

44. Psychotic Disorders & PTSD • Psychotic disorders – uncontrolled psychotic symptoms can also lead to less optimal decisions regarding health care, adherence, and risk behaviors. BHCs can help to monitor symptoms and provide liaison with specialty care and screening for hospitalization when necessary • PTSD– we have found high rates of undiagnosed and untreated PTSD in our population. BHCs have provided identification of PTSD symptoms and have helped to normalize the experience for patients. In addition, brief interventions have also served to help patients engage in specialty psych care, make better decisions about health care and risk behaviors, and access appropriate support services.

45. Substance Abuse Substance Abuse within the context of HIV disease is associated with: Poorer rates of adherence, Less engagement in care, and Higher rates risk behavior and disease progression. BHCs can play a role in screening, education, MI to build motivation for treatment, collaboration with other professionals and services, and referral for treatment. BHCs help to set the one for a non judgmental, harm reduction approach to substance abuse which makes an effort to maintain the patient engaged in HIV care well while also offering support for addressing substance abuse issues.

46. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!