“VA is the single largest provider of HIV care in the United States, treating more than 30,000 veterans with HIV across the country”
BALTIMORE — The presence of diagnosed mental health conditions—whose prevalence in people with HIV has grown overall in recent years—can have an important impact on retention in care and viral suppression in HIV patients, a new study shows.
The study, published this month in AIDS, was part of an effort to incorporate more studies of multimorbidities in patients with HIV that look at both mental and physical health, said co-author Keri Althoff, PhD, MPH, an assistant professor of epidemiology at Johns Hopkins Bloomberg School of Public Health in Baltimore. “Specifically, a lot of studies have been among older patients and often focused only on physical health conditions,” she said. “We want to look at the whole person.”
To look at the whole person—specifically the prevalence of mental health disorders in people with HIV and the effects of those disorders on HIV care—Althoff and her colleagues turned to the North American Cohort Collaboration on Research and Design (NA-ACCORD). Part of the International Epidemiologic Databases to Evaluate AIDS (IeDEA), NA-ACCORD is a collaboration of 29 cohorts including the VA Family of EHR Cohorts (VACo Family), which offers an unprecedented resource of data derived from the VA’s Electronic Health Record. The collaboration is widely representative of HIV care in the United States and Canada.
VA is the single largest provider of HIV care in the United States, treating more than 30,000 veterans with HIV across the country. Researchers from the VA Connecticut Healthcare System in West Haven participated in the study.
The study team examined records from patients age 18 and older who contributed data on prevalent schizophrenia, anxiety, depressive and bipolar disorders from 2008 to 2018, based on International Classification of Diseases code mapping. Depression and anxiety were chosen for inclusion because they are both highly common and would allow the researchers to see the larger prevalence of mental health disorders. Schizophrenia and bipolar disorders were chosen because, while they are uncommon, their prevalence is higher among people with HIV than in the population as a whole and are known risk factors for HIV transmission routes, Althoff said.
HIV Care was represented by retention in care—defined as having at least one HIV primary care visit within a calendar year—and viral suppression, which was defined as having an HIV RNA less than 200 copies/ml at the patient’s last measurement of the year.
The Findings
Among the 122,896 participants included in the study between 2008 and 2018, more than half (55.1%) were diagnosed with one or more mental health disorders—a percentage significantly higher than studies have shown for the general population. The prevalence of depression and anxiety grew over time, the study found, while the prevalence of bipolar disorder and schizophrenia remained stable.
While the study found retention in care was a bit lower for those with depression and anxiety, people with multiple (more than one) morbidities were more likely to be retained in care, Althoff said. She attributes that to the fact that many HIV clinics offer mental health services.
“If you are an individual and your mental health condition is having a greater impact on your quality of life than your HIV, then you are going to stay engaged in that HIV care to get that mental health care,” she said, adding that the provision of mental health services, either in the clinic or with a closely linked mental health clinic, is likely an important piece to keeping people in care.
The proportion of people with HIV in NA-ACCORD achieving viral suppression increased between 2008 and 2018, the study found; however, it was lower among those with bipolar disorder than those without and among those with schizophrenia than those without.
Although the difference was not dramatic, Althoff said, “the finding points to a subpopulation that we need to be mindful of—that individuals with bipolar disorder or mental health multimorbidities are having lower prevalence of viral suppression and raises questions as to what additional supports can be put into place to ensure that they have the greatest access to viral suppression.”
Keeping People With HIV in Care
Because the study ended in 2018—shortly before the COVID-19 pandemic, Althoff is interested in learning whether healthcare changes during the pandemic would have an impact on the study’s results. “As we all know, mental health dramatically changed during COVID for everybody,” Althoff said. “There is no reason to think it would be different for people with HIV, and we are hoping to update this paper relatively soon. I want to see what happened.”
In the meantime, the paper holds messages for clinicians and researchers in the VA and other health systems alike.
“I would say that, for clinicians, this is just a reminder to remain vigilant about screening for mental health disorders and then providing that engagement in mental health services when needed,” said Althoff. She said it is also important for researchers and program decision-makers to understand there might be differential barriers to viral suppression that need to be overcome among individuals with HIV mental health mulltimorbidities.
“We have a growing population aging with HIV, so both physical and mental multimorbidies are likely to continue to increase,” she said. “Our findings are showing that this mental health multimorbidity piece should never be overlooked, and the connections that the HIV clinics have to mental health services are really important and need to continue to be supported. And, if they don’t exist in certain areas—because we know in this country there are areas where there is not enough access to mental health services—we need to be cognizant of that, particularly among populations with HIV.”
- Lang R, Hogan B, Zhu J, McArthur K, (North American AIDS Cohort Collaboration on Research and Design [NA-ACCORD]) of the International Epidemiologic Databases to Evaluate AIDS [IeDEA]. The prevalence of mental health disorders in people with HIV and the effects on the HIV care continuum. AIDS. 2023 Feb 1;37(2):259-269. doi: 10.1097/QAD.0000000000003420. Epub 2022 Nov 10. PMID: 36541638; PMCID: PMC9782734.
