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July 20, 2020

Ending HIV and Tuberculosis—What Has Mental Health Got to Do with It?

Author Affiliations
  • 1Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle
  • 2Department of Global Health, University of Washington, Seattle
  • 3Columbia Vagelos College of Physicians & Surgeons, New York, New York
  • 4New York State Psychiatric Institute, New York, New York
JAMA Health Forum. 2020;1(7):e200852. doi:10.1001/jamahealthforum.2020.0852

The Global Fund to Fight AIDS, Tuberculosis, and Malaria recently launched an open consultation seeking ideas to inform its next strategy for 2023. A key question posed in this consultation process is, “If there were one thing you would suggest the Global Fund do differently… what would it be and why?” For us, the answer is to make mental health an integral part of the strategy to end these epidemics.

The Global Fund, a partnership of civil society, governments, the private sector, and technical agencies, is a pooled fund committed to the fight against the 3 epidemics of HIV, tuberculosis (TB), and malaria. The organization raises and disburses more than $4 billion annually, primarily from donor governments. The Global Fund’s board makes funding decisions based on country-specific input from key stakeholders and domain experts. For HIV alone, Global Fund investments support HIV prevention programs, testing, care, and treatment for youth, adults, and key populations (ie, people with greater vulnerability to HIV acquisition). However, the current Global Fund strategy ignores the crosscutting coepidemic of mental and substance use disorders. If treatment of these disorders were closely integrated with efforts to end HIV and TB, the prevention and care outcomes for these infections would be strengthened and global access to mental health care would be improved.1 Especially in settings where political will already exists, there is an opportunity for the Global Fund to fill the critical capacity and resource gap that would make such integration possible.2

Rationale for Integrated Care

Mental and substance use disorders, HIV, and TB are inextricably linked.3 Individuals with HIV are 19 times more likely to have TB, which is the leading cause of death for people with HIV. Individuals with TB and HIV have elevated rates of depression and other common mental disorders,4 which is linked with higher rates of outcomes. Globally, 1 in 8 people who inject drugs lives with HIV. Alcohol use and alcohol use disorders alone are associated with 10% of all TB infections and around 3% of deaths due to HIV.

Many countries that are significantly affected by cooccurring HIV and TB epidemics are having large challenges with retention in care, with only 70% of patients with HIV who start treatment continuing after 2 years. Meta-analyses suggest that depression is associated with increased odds of medication use and treatment of depression is associated with an increase in the odds of medication adherence by 83%.5

Individuals and communities with layered social and economic vulnerabilities are at the center of these synergistic epidemics, or syndemics, which have interacting effects that amplify disease burden in the populations they affect. People with preexisting mental health conditions or substance use disorders, who are at greater risk of HIV or TB infection in many contexts, as well as people living with HIV and/or TB who simply want support to lead thriving lives, need options for integrated mental and behavioral health care. A failure to address the syndemic nature of the interacting coepidemics of HIV, TB, and mental and substance use disorders in an integrated fashion risks misses the potential multiplicative benefit of addressing them together.

An Economic Argument

Economic modeling suggests that for every $1 invested in treating mental disorders, up to $5.70 is saved in economic cost and health returns.6 For HIV and TB, savings are estimated at $6.40 and $43, respectively.7,8 Integrating mental and substance use disorder treatment into HIV and TB platforms may synergistically increase those gains by reducing community transmission and drug resistance, as well as social and economic costs to individuals and households affected by these multimorbidities.9 In most sub-Saharan African countries where HIV and TB are most prevalent, most patients do not receive any structured screening for mental health problems and there is no formal integration of mental health care within HIV and TB care. What we need is an overhaul of the current approach to diagnosing and treating HIV and TB to include mental health and substance use disorders as a core package. Without addressing comorbid mental health problems among people most vulnerable to HIV and TB, the goals of the Global Fund will remain elusive.

Urgent Need with Coronavirus Disease 2019

It was already hard to see how global targets for HIV and TB would be reached without investment in mental health services prior to the coronavirus disease 2019 (COVID-19) pandemic, which has created new challenges for HIV and TB control by the Global Fund. A recent study estimated that in high-burden settings, HIV-associated and TB-associated deaths over 5 years may increase by up to 10% and 20%, respectively, compared with if there were no COVID-19 pandemic. But this time of disruption also brings opportunities. With increased attention on the mental health outcomes that COVID-19 is having on vulnerable groups and general populations, there are growing calls and recently released UN guidance regarding the need to integrate mental health into COVID-19 response and recovery plans. Building back better, with strengthened and resilient health care systems, would help ensure more robust pandemic preparedness, including the protection and scaling up of mental health support and services, and would also deliver greater progress on HIV and TB.

What Should the Global Fund Do?

The next Global Fund strategy needs to align its policies and guidance with recommendations from the World Health Organization’s strategy to end TB, clinical guidelines for HIV treatment and prevention, and guidelines for mental health and substance use disorder care, all of which acknowledge comorbidities like mental disorders. Organizations, including the US President's Emergency Plan for AIDS Relief, the World Bank, and UNAIDS, have highlighted the importance of integrated responses to these multimorbidities. The Global Fund needs to consider mental and substance use disorders as essential elements of “integrated patient-centered care” and critical to curbing the HIV and TB epidemics. It must build in funds not only for treatment but implementation research to find optimized strategies for service integration that maximize health outcomes—including mental health outcomes—while managing costs. Having led and shaped the global response to the world’s greatest infectious diseases over the past 18 years, it can demonstrate proactive leadership by investing in mental health. This investment will ultimately aid the Global Fund and the world in achieving its aspirational goals to end the HIV and TB epidemics.

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Article Information

Open Access: This is an open access article distributed under the terms of the CC-BY License.

Corresponding Author: Pamela Y. Collins, MD, MPH, Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Box 356560, Seattle, WA 98195 (pyc1@uw.edu).

Conflict of Interest Disclosures: Dr Wagenaar was supported in part by the National Institute of Mental Health (grant K01 MH110599). Dr Sweetland was supported by the National Institute of Mental Health (grant K01 MH104514) and was a compensated member of the board of directors of Chemonics International Inc until June 2019. No other disclosures were reported.

Additional Contributions: We are grateful to Claire Hoffman for her input on early drafts.

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