Gaps in mental health care for men who have sex with men (MSM), a population disproportionately affected globally by HIV, are limiting effective treatment and care for both HIV and mental illness, experts say.
“Mental health problems are an underappreciated barrier to successful treatment and prevention of HIV, and this is doubly true in low-income countries, and even more so for marginalized populations who are dealing with layers of stigma,” Brian Pence, an epidemiologist at the University of North Carolina (UNC)-Chapel Hill in the US, told IRIN.
“Every additional layer of social marginalization increases complexity and raises barriers to treatment for HIV and mental health,” he added.
Yet HIV prevention and treatment programmes fail to address adequately mental health, while mental health programmes often ignore HIV. HIV programme staff often lack training to spot or discuss the symptoms of deteriorating mental health with clients. Mental health programmes may neglect to see HIV status as a possible trigger for significant mental health conditions such as depression.
Advocates are calling for “wrap-around” care and task-shifting to community-based care providers to bridge the oft-siloed fields of care, experts say.
Heavy hidden burden
“Hidden groups like MSM are in many countries - and it is even worse when they are criminalized in some way - more vulnerable to mental health issues,” said Vikram Patel, professor of international mental health and at the London School of Hygiene and Tropical Medicine and director of the Centre for Mental Health at the Public Health Foundation of India.
The UN special rapporteur on the right to health has written that the criminalization of same-sex conduct contributes to deteriorating mental health for sexual and gender minorities, including MSM.
“State-sanctioned criminalization or pathologization of people for their sexual attractions or behaviour can only be seen as damaging in terms of mental health, and deteriorating mental health can certainly be a risk factor for HIV infection,” Patel said, adding that research on MSM and mental health in many countries is a “blind spot”.
A 2012 global survey by the Men Who Have Sex With Men Global Forum (MSMGF), a US-based advocacy group, identified competent mental health care as a key aspect of successfully getting MSM to access HIV services.
“Although some men did not name their pain as a form of poor mental health, when other men described feelings of depression, all the men recognized and endorsed an urgent need to address this phenomenon,” the survey reported.
In addition to weak mental health care being a barrier to effective HIV testing and treatment for people living with HIV, mental health problems can also significantly impair their ability to continue treatment, experts say.
“We know that depression has high prevalence in people living with HIV, but the integration of mental health treatment into HIV treatment services, which are often peoples' principal or even sole health care access point, is often minimal or non-existent,” said Pence from UNC-Chapel Hill.
Research from South Africa, where nearly 10 percent of MSM are living with HIV, suggests these gaps in care may be exacerbated by mental health providers’ stigma against HIV, and similarly, by HIV providers who stigmatize mental health illness.
According to Pence, “Poor referral mechanisms and practices between HIV treatment services and mental health services mean many HIV patients miss out on getting the mental health diagnoses and treatment they need.”
The World Health Organization (WHO) has recommended integrating mental health care into primary care for more than 30 years. However, progress remains piecemeal and even where integration has taken place at a policy level, cross-training is patchy.
But there are signs integration works.
“There is a good evidence base for the integration of psychiatric care - even staff who are not psychiatrists - into a wide range of medical settings, including HIV treatment settings,” explained Pence, referring to a method of integration known as “task-shifting” where primary care and community health workers take on specialized duties.
WHO’s 2013 comprehensive mental health action plan calls for better integration into HIV services and programmes.
According to Patel from the London School of Hygiene and Tropical Medicine, the first step should be to approach civil society groups helping MSM access HIV services “to start a conversation about mental health”.
But, he warned: “Such interventions need to speak the language of the communities they are intended to help. We have to avoid foreign psychiatric labels, for example, and talk about stressors in the environment - that way these men can connect the way they feel to their lives and their environment rather than some sense of shame.”