Interventions for Integrating Behavioral Health into HIV Settings for US Adults: A Narrative Review of Systematic Reviews and Meta-analyses, 2010–2020

Abstract

Mental health and substance use disorders can negatively affect physical health, illness management, care access, and quality of life. These behavioral health conditions are prevalent and undertreated among people with HIV and may worsen outcomes along the entire HIV Care Continuum. This narrative review of tested interventions for integrating care for HIV and behavioral health disorders summarizes and contextualizes findings from systematic reviews and meta-analyses conducted in the past decade. We sought to identify gaps in research that hinder implementing evidence-based integrated care approaches. Using terms from the Substance Abuse and Mental Health Services Administration-Health Resources & Services Administration standard framework for integrated health care, we searched PubMed and PsycInfo to identify peer-reviewed systematic reviews or meta-analyses of intervention studies to integrate behavioral health and HIV published between 2010 and 2020. Among 23 studies identified, only reviews and meta-analyses that described interventions from the United States designed to integrate BH services into HIV settings for adults were retained, leaving six studies for narrative review by the study team. Demonstrated benefits from the relatively small literature on integrated care interventions include improved patient- and service-level outcomes, particularly for in-person case management and outreach interventions. Needed are systems-level integration interventions with assessments of long-term outcomes on behavioral health symptoms, HIV viral suppression, HIV transmission rates, and mortality. HIV, primary care, and other providers must include behavioral health as a part of overall healthcare and must play a central role in behavioral health care delivery. Research is needed to guide their way.

Introduction

Mental health and substance use disorders, collectively referred to as behavioral health (BH) conditions, can negatively affect the ability to maintain good physical health, manage chronic illness, and attain optimal quality of life and functioning [1]. BH conditions such as depressive disorders, anxiety disorders, bipolar disorder, schizophrenia, and alcohol and other substance use disorders are among the most pervasive causes of disease and disability worldwide; in the United States (US), they affect roughly 20% of all adults [2], rank as the leading cause of disability, and account for 18.7% of years of life lost to disability and premature mortality [3]. More than 50% of all counties in the US do not have a licensed BH provider (i.e., psychiatrists, psychologists, clinical social workers, psychiatric nurse specialists, or marriage and family therapists; licensing requirements vary by state) [4]. A majority (67%) of adults with a BH disorder do not receive appropriate treatment, often due to health insurance barriers [5], though stigma associated with BH disorders and accessing BH treatment certainly plays a role in creating barriers to care [6,7]. Untreated BH disorders increase both suffering and the cost of patient care for co-occurring medical illness [8,9]. Among individuals with BH conditions who do seek care, 56% do so in a primary care setting, with 20% of all visits to primary care physicians including at least one of the following: depression screening; counseling; making a BH diagnosis or listing BH as a reason for the visit; psychotherapy; or provision of a psychotropic drug [10]. The prevalence of BH conditions in the general population and the relatively limited number of BH specialists suggest that primary care and other providers must play central roles in BH care delivery. Without services addressing BH, quality of life and physical health may suffer [11,12]. More dire still, the lifespan for people with BH disorders is 10–20 years shorter than those without BH disorders [13,14]. Integrating BH services into primary care settings improves the quality and patient-centeredness of care [15].

The Substance Abuse and Mental Health Services Administration-Health Resources & Services Administration (SAMHSA-HRSA) standard framework for integrated health care [16] assists providers in integrating primary and BH services to better address the needs of individuals with mental health and substance use conditions, whether seen in specialty BH or primary care provider settings. The framework is used for planning; creating a common language to discuss integration, progress, and financing; supporting assessment and benchmarking efforts; explaining integration efforts to stakeholders; and clarifying differences in vision between two or more partnering organizations [16]. As it applies to HIV services, the framework describes three levels of integration corresponding to how care may be organized: (1) coordinated care, in which collaboration between BH and HIV care is minimal or at a distance; (2) co-located care, where HIV-BH collaboration occurs on-site and with some degree of system integration; and (3) fully integrated care, characterized by close to full HIV-BH collaboration within an integrated or merged practice in which communication is consistent at the systems, team, and individual levels. However it is accomplished, integrating care for BH and HIV is essential for consistent, coordinated, person-centered, timely care. BH conditions are not static states but instead tend to cycle through acute exacerbations, sometimes due to situational stressors or treatment lapses; most are ameliorable to intervention, sometimes resulting in remission. It is therefore not surprising that BH conditions appear to impact the entire HIV Care Continuum [17,18], a widely used representation of the proportion of people tested for HIV, linked to HIV care, retained in HIV services, and virally suppressed [19]. For people with HIV (PWH), accessing care and treatment in multiple care systems can pose barriers to managing their multiple, often complex needs. Integrating BH screening and care into HIV testing and treatment settings shows potential to decrease new HIV infections and increase viral suppression among PWH [20] while also improving physical health, mental health, and quality of life [21].

BH conditions are both prevalent and undertreated among PWH [22–29]. Depression is one of the most common comorbidities affecting adults with HIV, with prevalence estimates ranging from 20–40% [30]. Estimates of posttraumatic stress disorder among PWH range from 10–74% [20]. Also prominent among PWH are substance use disorders, with prevalence estimates ranging from 21–74% [20]. Though effective treatments for BH conditions exist, and interventions to integrate these treatment approaches into primary care—including HIV care—have been tested in controlled studies, the extent to which integration interventions have been applied as usual treatment in health care settings remains a highly under-researched question. Even for what may be the most widely tested model of care integration, collaborative care, real world implementation of this approach has been limited and slow [31]. Further, benefits of collaborative care are not uniform across all BH disorders. Although existing evidence suggests that collaborative chronic care models across primary, specialty, and BH care settings are effective in treating depression and anxiety disorders, inconsistent effects have been reported for bipolar and substance use disorders [32].

Given the complexity of translating research into practice generally, but particularly in terms of scant recent research about tested interventions for integrating care for comorbid HIV and BH conditions, we undertook a narrative review to (1) summarize and contextualize findings from systematic reviews and meta-analyses conducted in the past decade and (2) identify gaps in research that hinder practitioners from using evidence-based approaches to implementing integrated care.

Methods

We sought to identify peer-reviewed systematic reviews and meta-analyses of interventions for integrating BH into HIV prevention and care settings for adults in the US. Our aim was to distill and summarize what these studies learned about tested approaches to care integration. We engaged an Informationist at Columbia University’s medical school library to identify relevant studies published between 2010 and 2020. The search was conducted from April 15, 2020 to May 15, 2020 using PubMed and PsycInfo. We determined three broad search categories – HIV prevention, treatment, care; behavioral health, mental health, substance, use; integration. We derived search terms for integration from the SAMHSA-HRSA standard framework for integrated health care, including co-location; coordination and collaborative care [16]. The key words and MeSH-terms used to search PubMed and PsycInfo for all components in keywords, titles, and abstracts are shown in Table 1.

Table 1.

Key search terms for systematic review articles and meta-analyses about integrating behavioral health into HIV prevention and care, 2010–2020.

Search Categories	Search Terms
HIV Prevention, Treatment, Care	HIV Prevention, HIV Treatment, HIV Care
Behavioral Health, Mental Health, Substance Use	Care (screening, referral, treatment, treatment planning, counseling, therapy, psychotherapy) Mental health, mental health disorder, mental disorder, psychiatric disorder Substance Use/Misuse/Abuse, Substance Use Disorder, Addiction, Hazardous Substance Use
Integration	Integration (Integrated care) Co-location (Co-located care) Coordination (Coordinated care, care coordination) Collaborative care

Studies were restricted to the English language and those comprising any interventions carried out in the US that included people aged 18 years or older. This approach identified a total of 23 peer-reviewed systematic reviews or meta-analyses related to intervention studies of BH-HIV integration. Figure 1 shows the flow diagram for systematic reviews and meta-analyses of interventions to integrate BH into HIV care. Using Mendeley to share the search results among the study team, five team members reviewed each identified abstract and met to discuss abstracts identified for further review and reach consesnus on abstracts to be included, i.e., whether the article presented interventions focused on the integration of BH services into HIV settings and met other inclusion criteria. When it was not clear from the abstract, the team members examined the full article. Only reviews and meta-analyses that described interventions designed to integrate BH services into HIV settings were retained. Each article was then reviewed by a team member using a template to record information on the interventions presented including: study design, type of intervention, intervening party, study participants, whether mental health disorders, substance use disorders, or both were addressed, and where the studies took place. After review of the full article, the team met to share and compare results. Articles that were not retained included those that examined HIV risk behaviors, effects of BH conditions on HIV medication adherence as a primary outcome, other aspects of HIV assessment or care among people with BH disorders, associations between provider characteristics and integration intervention strategies, or models of integration without describing and/or analyzing how services for BH disorders and HIV were integrated.

Fig. 1.

Flow diagram for systematic reviews and meta-analyses of interventions to integrate behavioral health into HIV prevention and care

Six articles (26.1%) were retained for narrative review (Figure 1). Whereas systematic reviews focus on answering specific questions, narrative reviews are evidence-based summaries on a defined topic and are particularly well-suited to outlining general principles [33]. Each member of the study team reviewed one or more of the full texts; at least two study team members described, in detail, the specific questions each peer-reviewed systematic review or meta-analysis sought to answer (e.g., did single-site service integration produce better retention outcomes than multi-site service coordination?) and what the findings showed.

Results

Effects of the different levels of the SAMHSA-HRSA framework

Single-site integration augments multidisciplinary coordination (i.e., improves inter-provider communication; reduces time spent scheduling/coordinating patient visits; considers/resolves competing treatments for dual/triple diagnoses) and reduces barriers to patient access, but challenges systems in terms of implementation (i.e., prohibitive cost; too few specialized staff) when a fuller continuum of specialized care involving multiple treatment modalities is needed, particularly in low-resource settings [34]. Multi-facility integration may appear to serve multi-morbid patients comprehensively (i.e., provide a cost-effective array of services for patients with complex needs), but appropriate coordination and referral mechanisms are crucial to have in place to prevent fragmented, poorly coordinated, delayed care [34]. Effective collaboration and coordination require formal and informal productive relationships throughout the system between providers and within teams, as well as between staff and patients [35]. Additionally, training and operational support to incentivize health workers, supportive institutional structures, dedicated resources, leadership, “political” will to explicitly define integration goals and strategies, and effective managerial oversight are all needed [35]. Benefits of this model, according to patients, include reduction of physical barriers to accessing services (e.g., transportation between service settings); removal of excess burden for those with mental and/or physical disabilities; and improvements in confidentiality that might be breached when a patient is seen accessing a specialty mental health or HIV facility, thereby decreasing stigma and patient anxiety about accessing services [34].

Impact of case management and outreach on HIV care continuum improvements

The care integration interventions most consistently associated with improved medical outcomes—in particular, antiretroviral prescribing, immunological outcomes, and healthcare utilization—are sustained in-person case management and outreach interventions [36]. Case management interventions are associated with improvements in immunological outcomes, but are not clearly associated with other outcome measures [36]. Active case management by non-clinicians offers considerable potential (i.e., offering resources, psychosocial support, education on how to interact with doctors and clarify information they provide; continuity of care), especially in low resource settings with shortages of mental health specialists [4], as long as appropriate training and support are provided and case manager time is realistically allotted [34]. Outreach interventions demonstrate improvements (or non-inferiority) with respect to mortality, receipt of antiretroviral medications, immunological outcomes, improvements in healthcare utilization, and lower reported healthcare costs when compared to usual care [36].

Health care settings in which interventions improved the integration of HIV and BH care

Direct comparisons between primary care, specialized HIV, or specialized BH sites utilizing the same integration intervention have yet to be reported, but wherever integration does occur, important benefits in both patient and service outcomes have been found [37]. For example, integrated psychosocial interventions and directly observed opioid agonist treatment, when offered together with antiretroviral treatment, have been shown to improve HIV viral suppression [38]. Optimal screening for any co-occurring conditions may be more likely in specialized rather than primary care settings [37]. Achieving positive patient outcomes depends on overcoming implementation barriers, including appropriate financing, workforce training, and challenges in combining differing clinical practices and organizational stances toward clients with BH disorders [37].

Effective integration by specialists and through task-shifting among non-specialized staff

Task shifting to non-specialists is a common intervention for overcoming human resource constraints, with trained non-BH healthcare or lay workers providing health education, counseling, and outreach activities that are acceptable to patients [39]. Although task-shifting can improve some outcomes (e.g., reducing depression), a potential downside is that even well-trained staff are at risk of stress from increased workloads and integration policies that create competing demands on staff members [35].

Benefits of involving patients in HIV-BH integration

Involving patients as active partners in improving integration (e.g., through service navigation; use of tools to manage/monitor vital elements of treatment progress) within the treatment process is a promising approach. Interventions that include self-management and peer-support to ensure treatment continuity show greater overall improvements in mental health and substance use outcomes [34], both by bridging gaps in care coordination and by empowering patients to guide their own treatment. Putting the patient at the center of service delivery and responding holistically to the patient’s diverse needs (e.g., socio-economic; cultural) underpins all aspects of integration, particularly as integration often involves extending services to marginalized groups who experience significant and multiple stigmas, and peer-to-peer support facilitates use of integrated care services [35].

Effects of practice-based BH interventions on HIV outcomes

The practice-based intervention that has been the focus of most research stems from the collaborative care model for chronic BH conditions [32]. Collaborative care is an intervention in which primary care and BH care providers use shared care plans that incorporate patient goals [40]. One article that comprised both a systematic review and a meta-analysis to examine outcomes of practice-based interventions for depression and chronic medical conditions in adult primary care patients [41] focused on interventions that targeted the care process within a system of care, such as coordinated care, integrated care, or collaborative care. The systematic review identified 12 controlled studies that investigated outcomes of at least 6 months’ duration for depression and one or more chronic medical conditions—including HIV/AIDS—defined as priority conditions by the Agency for Healthcare Research and Quality [42] and the Institute of Medicine [43]. All included studies characterized their intervention as a form of collaborative care rather than another practice-based intervention. Recipients of collaborative care—which included a care manager to direct overall treatment—showed significantly greater improvement in depression outcomes as compared with patients receiving usual care or enhanced usual care; specifically, significantly greater depression symptom improvement, symptom-free days, response rates, remission rates, treatment satisfaction, and mental health-related quality of life were found. The meta-analysis—focused on a subset of six studies for which “outcomes reported by a sufficient number of studies” were “homogeneous enough”—showed greater physical health quality of life at six and 12 months. However, only one of these studies specifically focused on PWH, and this study did not find improved HIV outcomes.

HIV outcomes for BH integration at different levels of care systems

For multidisciplinary interventions and multi-faceted integrated care interventions, mixed results were found across outcomes (i.e., HIV antiretroviral therapy, CD4 cell and viral load counts, healthcare utilization, psychosocial, and health-related quality of life) [36]. Mixed effects of integrated care on HIV outcomes were found even with comprehensive, directly administered opioid agonist treatment and antiretroviral therapy, counseling, psychiatric treatment, and social work compared to standard care in an outpatient clinic [38], with only 20% of studies that focused on integrated approaches finding improved viral suppression. Without supportive institutional structures and dedicated resources, leadership, effective managerial oversight, and an organizational culture actively working toward integration [35], any single intervention is unlikely to be well-implemented or sustained.

Discussion

This narrative review was undertaken to provide a synthesis of lessons learned from a decade of systematic reviews and meta-analyses identified in PubMed and PsycInfo about tested interventions for integrating BH services into US HIV settings for adults with these commonly co-occurring health conditions. In this review, we identified 23 studies but only retained six that specifically described interventions for integrating BH services into HIV settings. These studies documented benefits of integrated care interventions in both patient and service outcomes [37]. What we can discern across the studies we reviewed is that both multi-site and single-site interventions have potential to reduce barriers to care and facilitate care coordination. However, both require that system challenges are appropriately addressed. Single-site interventions have financial and staffing challenges and multi-site interventions require establishing both informal and formal relationships within, between, and outside the sites. The interventions most consistently associated with improved HIV medical outcomes and healthcare utilization are sustained in-person case management and outreach interventions [36]. Creative utilization of staff via task-shifting, peer support, and collaborative models of care have shown benefits to behavioral health outcomes. Yet all of the above require staff training, organizational support, provider and institutional buy-in, and sufficient investment to prioritize the integration processes.

The dearth of tested interventions described in these reviews and the lack of direct comparisons of interventions to integrate BH into HIV care are critical gaps that must be filled for optimal patient care and service delivery. Across intervention models, the potential to provide structure, accountability, and support for treatment has been realized in some settings where interventions have been tested. Future controlled trials and implementation science studies using comparative and hybrid effectiveness approaches would provide evidence that care systems could use to select the most appropriate interventions to meet their particular patients’ needs and to scale them up within a wide range of settings, such as primary HIV care practices and federally qualified health centers. The literature that we uncovered highlights the need for studies on systems-level interventions to integrate care, also referred to as the macro-level, of which we found none (Figure 1). Further, research about the comparative effectiveness of these interventions across the three levels of the SAMHSA-HRSA integration framework would offer tremendous advances in our understanding of how best to organize and deliver integrated services.

This review encompassed two databases (PubMed and PsycInfo) that are commonly accessed for peer-reviewed reports of interventions related to both BH and HIV. We sought to summarize and characterize these BH-HIV integration interventions for their potential to be implemented in health settings focused on primary care for HIV. We did not conduct a systematic review or evaluate the quality of the evidence synthesized here; each review or meta-analysis that we reviewed did that themselves, with varying degrees of rigor utilizing different frameworks. Moreover, we adopted a definition of integration that was broad enough to capture a range of integration approaches for a wide array of BH conditions, but we limited our consideration of systematic reviews and meta-analyses to those that focused on interventions that tested how to combine BH services into HIV settings. Individual studies that were part of this review also varied in defining integration. As Vold and colleagues [38] observed, narrower definitions of integration resulted in few relevant studies fulfilling their inclusion criteria, comprising a chief limitation in their study. Additional limitations of the studies we reviewed include the dearth of assessments of long-term outcomes (beyond six to 12 months), including for effects on BH symptoms, HIV viral suppression, HIV transmission rates, and overall mortality [37]. Given that many of the BH conditions examined in the studies we reviewed are chronic in nature, as is HIV, longitudinal studies are critically needed to understand how best to offer comprehensive, patient-centered care for these comorbidities.

Findings from these studies are a recipe for future implementation science studies that can assess integration barriers and facilitators within one or more health care settings and test different implementation strategies, such as training and building institutional structures to measure how they affect adoption and health-related outcomes of a tested intervention. Finally, people at the center of care integration—those living with HIV and one or more BH conditions—are vital to include in any future research that seeks to fill the gaps our review identified. Although not a focus of the papers included in this narrative review, future research should explore the ways in which geography may be destiny: rural and urban healthcare settings offer disparate access to needed and high-quality services [44], despite the rise of virtual care seen during the COVID-19 shutdown [45]. This research agenda is a tall order, and sustained effort is needed to reduce the human costs and system burden that have, for decades, taken a heavy toll on the physical health, mental health, and quality of life of people with these co-occurring conditions. Both the prevalence of BH conditions [46] and the relatively limited number of US BH specialists [4]—a disparity that was exacerbated during the COVID-19 pandemic—suggest that HIV, primary care, and other providers must include BH as a part of overall health assessments and must play a central role in BH care delivery. Research is needed to guide their way.