Presidential Advisory Council on HIV/AIDS Public Comment

David J. Martin, PhD, ABPP
Senior Director Office on AIDS
Public Interest Directorate
American Psychological Association
Before the 51st Presidential Advisory Council on HIV/AIDS Meeting
Washington, DC

April 22, 2013

Good Afternoon. My name is David Martin, PhD, and I am the Senior Director of the Office on AIDS at the American Psychological Association (APA). On behalf of APA, I would like to thank you for PACHA’s continued leadership.

Mental and behavioral health services are essential for reducing the incidence of new HIV infections, as well as for increasing adherence to treatment regimens and improving health outcomes for people living with HIV/AIDS. The HIV Costs and Services Utilization Study (HCSUS), the first study of its kind to examine mental health and substance use among a nationally representative sample of those living with HIV/AIDS, found that almost 50 percent of the participants had some type of mental health issue and nearly 40 percent reported substance use other than marijuana (Bing et al., 2001). Those living with HIV/AIDS and a mental health disorder and/or substance use problem were more likely to experience difficulties with treatment compliance and more likely to engage in risky behaviors relating to disease transmission.

While biomedical interventions for HIV prevention have made great strides, less attention has been focused on the integration of behavioral interventions as an essential part of effective biomedical approaches. To ensure that biomedical interventions and treatments are maximally successful, behavioral factors, such as those that affect medication adherence and treatment uptake must be addressed (Weiss et al. 2008). Current understanding of HIV prevention and treatment points to the need for integrated strategies that include behavioral, biomedical and structural approaches for the reduction of HIV transmission and disease progression. Behavioral approaches combined with biomedical strategies optimize the effectiveness of biomedical interventions; increase access to care; increase retention in care; increase treatment adherence; reduce overall cost of care; reduce HIV-related stigma; and address comorbid mental health and substance abuse issues (APA’s Resolution on Combination HIV/AIDS Prevention, 2012). For example, studies examining the effectiveness of medical interventions (e.g., Truvada) to reduce HIV transmission demonstrated that treatment adherence was critical in medical interventions’ effectiveness in reducing HIV risk (Grant et al. 2010; Abdool Karim et al. 2010). Recently reported data from large scale HIV prevention trials (e.g. Vaginal and Oral Interventions to Control the Epidemic (VOICE) substantiated these concerns and underscored the important roles that psychology should play in the prevention and treatment of HIV/AIDS. The utility of integrated behavioral-biomedical approaches to HIV prevention is applicable in both global and domestic contexts.

Psychological and behavioral interventions that enhance knowledge and build skills while attending to issues related to health disparities, poverty and HIV/AIDS stigma are useful in increasing medication adherence and treatment uptake (Liebowitz et al., 2011; Underhill et al., 2011). Psychology has made and continues to make significant contributions to the development, dissemination and evaluation of HIV prevention approaches; psychology is also positioned to address the unique mental health needs of people living with HIV/AIDS.

The American Psychological Association (APA), which represents 134,000 members and affiliates, strongly endorses the value of integrated behavioral-biomedical interventions to reduce HIV transmission, to improve the mental health of those living with HIV and AIDS and to reduce HIV-related disparities. This position has led to four priority areas of emphasis for us.

  1. Ryan White Program Continuation. APA fully supports continuation of the Ryan White program through the most feasible option available and full implementation of the Affordable Care Act. Ryan White programs have been at the forefront of integrated care models for people with HIV. As the transition from Ryan White Care Act-funded programs to programs funded under the Affordable Care Act progresses, healthcare for people with HIV should continue to integrate health and mental health care. APA welcomes calls for greater inclusion of essential support services in the Ryan White program as described in President Obama’s FY 2014 budget proposal, as well as ACA provisions that expand access and utilization to mental health and substance abuse services. Providers accessed for services related to HIV/AIDS might not know how to identify or treat mental health and substance use issues. Ensuring that resources and training for mental health and substance use treatment services are maintained in the Ryan White programs is vital. Finally, for those transitioning from RWCA-funded care to ACA-funded care, every effort should be made to ensure that the integrated care received under RWCA is not interrupted by the transition; lapses in treatment for people with HIV represent substantial medical risk.

  2. Combination HIV Prevention. Psychological and behavioral approaches should be central in planning and scaling-up HIV prevention and expansion of anti-retroviral treatment to promote uptake and maximize adherence. Prevention should be part of integrated care.

  3. HIV and Employment. As HIV treatments continue to improve and as more people with HIV are treated under the Affordable Care Act, more people with HIV will be able to work.  Planning for increased resources to assist people with HIV/AIDS reenter the workforce or enter the workforce for the first time is vitally needed.

  4. Federal Advisory Panels. Psychology provides unique benefits to health and wellness. To ensure that behavioral approaches and behavioral science continue to shape national HIV/AIDS policy, APA recommends greater inclusion of psychologists on federal advisory committees such as PACHA. 

Thank you. 

References

Abdool Karim, Q, Abdool Karim, S.S., Frolich, J.A., Grobler, A.C., Baxter, C., Mansor, L.E., … Taylor, D. (2010). Effectiveness and safety of tenofovir gel, an antiretroviral microbicide, for the prevention of HIV infection in women. Science, 329, 1168-1174.

Bing, E.G., Burnam, M.A., Longshore, D., Fleishman, J.A., Sherbourne, C.D., London, A.S., … Shapiro, M. (2001). Psychiatric disorders and drug use among human immunodeficiency virus–infected adults in the United States. Archives of General Psychiatry, 58(8), 721–728.

Grant, R.M., Lama, J.R., Anderson, P.L., McMahan, V., Liu, A.Y., Vargas, L., … Glidden, D.V. (2010). Preexposure chemoprophylaxis for HIV prevention in Men who have sex with men. New England Journal of Medicine, 363, 2587-2599.

Liebowitz, A. A., Byrnes Parker, K. & Rotheram-Borus, M. J. (2011). A US policy perspective on oral preexpsoure prophylaxis for HIV. American Journal of Public Health, 101, 982-985.

Underhill, K., Operario, D., Skeer, M. R., Mimiaga, M. J., & Mayer, K. H. (2011). Packaging PrEP to prevent HIV: An integrated framework to plan for pre-exposure prophylaxis implementation in clinical practice. Journal of Acquired Immune Deficiency Syndrome, 55(1), 8-13.

Weiss, H.A., Wasserheit, J.N., Barnabas, R.V., Hayes, R.J., & Abu-Raddad, L.J. (2008). Persisting with prevention: The importance of adherence for HIV prevention. Emergent Themes in Epidemiology, 5(1), 8.

Contacts

David J. Martin, PhD, ABPP  
Senior Director, Office on AIDS  
Public Interest Directorate   
American Psychological Association      

Leo Rennie
Senior Legislative and Federal Affairs Officer
Public Interest Government Relations Office
American Psychological Association