A model of integrated primary care for HIV-positive patients with underlying substance use and mental illness

Abstract

There is a high burden of underlying substance use and mental illness in HIV-infected populations. HIV-care settings provide an important opportunity to assess substance and mental health needs among HIV-positive patients and to provide or make referrals for appropriate treatment services. In 2003, with funding from the Center for Substance Abuse Treatment (CSAT), we developed a model of integrated substance-use counselling and referral for treatment within a primary care HIV-care setting at The Miriam Hospital in Providence, Rhode Island. The project uses a multidisciplinary approach to provide linkage to treatment services for substance use and mental illness as well as to help participants with social service needs, such as housing and medical coverage, to ensure continuity of care and optimal HIV treatment adherence. Twelve percent of the 965 HIV-infected patients in care at our center have been enrolled in the project. Of these, all have a current substance-use disorder and 79.3% have been diagnosed with a mental illness. In addition, most participants are hepatitis C-positive (HCV) (65.5%). The majority of participants are on antiretroviral therapy (76.7%). Participants have been referred for the following treatment modalities: intensive outpatient services, methadone, buprenorphine, outpatient services and residential as well as individual and group counselling. Our model has been successful in assessing the substance-use and mental health needs of HIV-infected individuals with numerous co-morbidities and referring them for ancillary medical and social services.

Interventions and approaches to integrating HIV and mental health services: a systematic review

“…In terms of treatment modalities, eight out of the 12 studies involved interventions that integrated HIV and mental health services (Andersen et al 2003, Sullivan et al 2015, Odokonyero et al 2015, Adams et al 2012a, Andersen 2012, Husbands et al 2007, Adams et al 2011, Adams et al 2012b) while four studies involved interventions that integrated HIV, mental health and substance abuse services (Wolfe et al 2003, Zaller et al 2007, Sacks et al 2011, Bouis et al 2007. Table 4 lists the papers that described interventions which had case managers who integrated services for patients through a care plan.…”

“…Out of the 12 studies, four described integrated care led by a nurse (Andersen et al 2003, Sullivan et al 2015, Odokonyero et al 2015, Adams et al 2012a, three described integrated care led by primary care staff (Andersen 2012, Wolfe et al 2003, Zaller et al 2007, three led by a social worker (Husbands et al 2007, Adams et al 2011, Bouis et al 2007, one led by a depression-care manager (Adams et al 2012b) and one that was integrated by the patient (Sacks et al 2011). In most of the studies, the case manager was responsible for providing or facilitating integrated care by linking patients and assisting them to access necessary services as part of an integrated treatment plan (Sullivan et al 2015, Andersen et al 2003, Husbands et al 2007, Zaller et al 2007, Bouis et al 2007.…”

“…In 12 of the studies, integration of services involved the use of a non-physician, such as a nurse or a social worker, acting as a case manager responsible for developing an integrated treatment care plan and facilitating referrals. Nine of the studies were conducted in a high-income country, of which eight were in the US (Andersen et al 2003, Sullivan et al 2015, Adams et al 2011, Wolfe et al 2003, Zaller et al 2007, Adams et al 2012b, Sacks et al 2011, Bouis et al 2007) and one in Canada (Husbands et al 2007); one was conducted in a middle-income country, South Africa (Andersen 2012); and two were conducted in low-income countries, in Uganda (Odokonyero et al 2015) and in Tanzania (Adams et al 2012a). Eleven studies were reported in full papers and one was a conference abstract (Andersen 2012).…”

“…Of the 45 papers, only two studies described integrating HIV services within existing mental health services (Rosenberg et al 2010, Lemmon andShuff 2001) while in the remaining papers, mental health and/or substance abuse services were integrated within existing HIV services. In 10 of these papers, these services were integrated in primary care settings (Farber et Williams 1995, Winiarski et al 2005, Feingold and Slammon 1993, Wolfe et al 2003, Zaller et al 2007, Wright and Shuff 1995, Esposito-Smythers et al 2014, Nebelkopf and Penagos 2005, Dodds et al 2004). …”

“…Eleven studies were reported in full papers and one was a conference abstract (Andersen 2012). Of these, there were two descriptive studies (Andersen et al 2003, Zaller et al 2007, three RCTs (Adams et al 2012b, Husbands et al 2007, Sacks et al 2011, two nonrandomized intervention studies (Bouis et al 2007, Adams et al 2011, one cohort study (Adams et al 2012a), one case-series (Odokonyero et al 2015), one cross-sectional study (Wolfe et al 2003), one mixed-methods study (Andersen 2012) and one qualitative study (Sullivan et al 2015).…”