By Karine Dubé and Jeff Berry

In 25 years of hosting the Conference on Retroviruses and Opportunistic Infections (CROI), this year’s conference marked the first time a plenary was dedicated to mental health issues among people at risk or living with HIV. 

Dr. Robert H. Remien of Columbia University delivered the keynote on “Addressing Mental Health: A Crucial Component to Ending the HIV Epidemic.” 

Mental health contributes a four to tenfold increased risk of HIV acquisition. Multiple co-occurring conditions—such as depression, heavy use of alcohol, and stimulant use—can amplify HIV risk. 

Screening and treatment for mental health disorders, including depression, can maximize the efficacy of HIV prevention methods, including pre-exposure prophylaxis (PrEP).

There are potential biological pathways between mental illness and HIV health outcomes. For example, depression can have direct effects on the immune system. HIV also crosses the blood brain barrier, and thus can cause immune activation in the brain and the central nervous system (CNS). The chronic inflammation response to HIV infection can also be a contributing factor to mental disorders. People living with HIV should adhere to ART to minimize the effects of HIV replication in the brain and the entire body.

Mental health issues can also contribute poor outcomes along the entire HIV treatment continuum. For example, mental health issues can contribute to increased risk behaviors (e.g., HIV infection), delayed (or lack of) HIV testing and care initiatives, as well as poor retention in care, ART initiation, and ART adherence. Depression is significantly associated with non-adherence to ART in several independent samples in the United States and around the world. Addressing mental health issues will be essential to achieving the 90-90-90 treatment goals around the world. Concurrent vulnerabilities, such as food insecurity, domestic violence, and stigma and discrimination can also contribute to sub-optimal outcomes. 

There are screening tools and efficacious treatment available. We need to make those treatment options available. Of all prevalent cases of depression, for example, 47% are recognized clinically, 24% receive treatment, 9% receive adequate treatment, and only 6% achieve remission. In the United States and globally, mental health remains a chronically underfunded issue, and the majority of people who need care do not receive it. 

Messaging around the U = U (Undetectable = Untransmissible) [preventionaccess.org] campaign may reduce psychological distress around HIV. There is now evidence that the risk of HIV transmission from people living with HIV who are virally suppressed on antiretroviral therapy is negligible to non-existent. The U = U campaign provides hope that we can reduce stigma around HIV. Dr. Remien called for more research around the possible psychosocial benefits of the U = U campaign.

We need stronger advocacy in dealing with mental health issues in the United States and abroad. Dr. Remien called for more leadership, and asked the HIV field to lead the way in better integrating mental health into primary care. Like HIV, mental health issues can be effectively treated. 

May is Mental Health Awareness Month in the United States. Help us raise awareness around mental health!